Tony breaks his back
In September 2013, Tony broke his back and had to have surgery. He believed he had accident cover through his insurer, Sorted Insurance. However, when he made a claim to Sorted Insurance, it found he only had sickness policies in place, so he was ineligible for a lump sum and some payments while he was recovering. Tony didn’t understand how this mix-up happened.
Tony comes to FSCL
In April 2014 we began to investigate Tony’s complaint. We reviewed all past correspondence between Tony and Sorted Insurance to look at what kind of cover Tony had taken out, and where it all turned sour.
Tony said he wanted a refund on the sickness policy premiums he had paid, because the cover under that policy was not the type of cover he had wanted.
The 2009 policies
Tony said he met with Sorted Insurance in 2009 to arrange insurance cover. Tony gave conflicting information to FSCL about the cover he thought he was taking out in 2009.
On one occasion Tony told our case manager that in 2009 he had an existing accident policy with Sorted Insurance in place, and that he wanted to apply for a sickness policy as well. Tony said Sorted Insurance had misunderstood the cover he was seeking in 2009 and changed his existing accident policy to a sickness one, and then he ended up with two sickness policies.
Tony also told our case manager on another occasion that in 2009 he was applying for a new accident policy, because as a farmer, it made sense for him to have an accident policy in place.
We reviewed the documentation. In 2009 a letter confirming the new policy Tony had taken out that year was sent to him. The letter confirmed the new policy was a sickness policy. Also, the application for cover form clearly stated it was an application for sickness cover. Tony also had no existing accident policy in 2009; his only existing policy with Sorted Insurance in 2009 was a critical illness policy.
We thought that in all the circumstances, Sorted Insurance had not misled Tony. It was reasonable to expect Tony would have seen on the application form and the confirmation letter that the policy he had applied for in 2009 was a sickness policy. We found that Sorted Insurance was not required to provide Tony cover as if he had taken out an accident policy in 2009.
The 2010 policy
In May 2010 another Sorted Insurance salesperson met with Tony, and he took out an accident policy. A confirmation letter was sent to Tony’s address a couple of weeks later confirming the accident policy was in place. We thought that Tony might have confused this meeting in 2010 with the 2009 meeting; Tony thought he had taken out an accident policy in 2009, but he had actually taken it out in 2010.
To make matters worse, from January 2011, all correspondence from Sorted Insurance to Tony was sent to the wrong address. This meant Tony could not review Sorted Insurance’s summary of his policies to see if he was paying for the correct policy. Tony did not know he had been paying for a sickness policy (not an accident policy), from 2009 onwards.
Furthermore, the 2010 accident policy was due for renewal in May 2011. Tony did not pay the renewal premium and because mail was being sent to the incorrect address for Tony, he did not receive Sorted Insurance’s policy lapse notices. Following no responses to the lapse notices, or to a phone call, Sorted Insurance cancelled the 2010 accident policy.
This meant that when Tony broke his back in 2013, Tony’s only existing policies were the 2009 sickness policy, and the critical illness policy, neither of which provided cover where a person has an accident.
Resolution
Sorted Insurance had no records to explain why it had the wrong address for Tony from early 2011 (especially since it had the right one in the past). Sorted Insurance offered to cancel the 2009 sickness policy and refund Tony the premiums he had paid since 2013. Sorted Insurance also said the amount refunded could be put towards the 2010 accident policy premiums, so that policy could be reinstated. Sorted insurance said upon back payment of the premiums it could assess whether Tony had cover under the 2010 accident policy.
Tony decided to cancel the 2009 sickness policy and accept the refund of premiums but chose not to reinstate the 2010 accident policy because he no longer wanted to deal with Sorted Insurance.
The lesson
It pays to be cautious about what kind of insurance policy you are taking out. Even if you are dealing with a representative, you should check the policy documentation yourself to make sure you have got the cover you think you have, and keep an eye out for statements in the post.
