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Claim decision disputed

Kaia had a package of accident and sickness policies.

In 2019, after a car crash that left her leg severely injured, Kaia made a claim under her accident policies. The insurer made payments to Kaia for a 180-day period. They said this was the maximum benefit under the policies.

Kaia was not satisfied with the outcome of her claim. She believed she should qualify for further payments. She had a partial disability and ongoing medical treatment costs she had to pay. The injury also affected her work and the quality of her life.

Kaia asked FSCL to investigate her claim.


The insurer said Kaia was not entitled to further payments. She would only be eligible for other benefits if she was totally and permanently disabled. The medical evidence did not support that Kaia was totally disabled.

Kaia accepted that she was not totally disabled, but she believed she was entitled to further payments. She highlighted different parts of the policy wording that she thought may be relevant to her claim.


After reviewing the list of cover Kaia had and the policy wording, we concluded that the insurer had paid Kaia the maximum benefit available to her.

Parts of the policy wording that Kaia had highlighted to us were not relevant to her claim. Some parts only applied if the insured was totally and permanently disabled. Other parts did not apply to her claim because they were not part of the package of cover that she had paid for.


Kaia accepted our view, but she was disappointed with the insurer. She felt the policies should have had more cover for partial disability, particularly because she had paid $43,000 in premiums over the last 20 years for her accident and sickness policies.

Kaia asked us to tell the insurer that she was not satisfied and that they would lose her as a customer if they would not make further payments to her. The insurer then offered a $250 goodwill payment, which Kaia accepted.

We suggested to Kaia that she may want to speak with a financial adviser about whether the policies were suitable for her. She had the policies for over 20 years. It appeared she had not reviewed whether they were suitable for her current circumstances.

Insights for consumers

It is important that consumers regularly review their insurance policies to make sure they remain suitable for them and that they maintain a suitable level of cover. Consumers may wish to take advice from a financial adviser.

The Insurance Council of New Zealand have a step-by-step guide on their website to help consumers review their insurances. They call this an insurance health check.