Mediation case studies

In the 1990s, Ian and Maeve took out life insurance that included Critical Illness Cover. They made complaints about their policy to the FSPO. Ian made a claim under the Critical Illness section which was rejected. Ian and Maeve felt the premiums were increasing far more than they expected, so they stopped paying them. A year later, they decided to cash in the policy and access the fund that had built up from their premiums. They were shocked to find that the policy had not been cancelled when they stopped paying for it and the funds available had been used up to pay for their premiums.

Ian and Maeve’s insurer said that without an instruction to cancel the policy from the policy holders, the fund was used to pay the premiums.

Ian claimed for critical illness cover for angioplasty in 2015. His claim was rejected because the policy did not cover angioplasty. Several years later, Ian complained to the insurer about this rejection. The final response he got from the insurer noted that the claim had not been fully assessed at the time, as Ian had not provided it with the name of his specialist. Ian disagreed and said he had already done this. Following back and forth conversations in mediation, Ian agreed to give the insurer the name of his specialist and the insurer agreed to reassess Ian’s critical illness claim.

On further assessment, it turned out that Ian had not had angioplasty. Instead, he had actually suffered a heart attack, which was covered under his critical illness policy. The insurer agreed to pay the full Critical Illness benefit, plus a refund of the critical illness premiums Ian had paid from the time of the heart attack to when all payments ceased, plus a refund on the life insurance premiums paid from the time of his illness to when the payments fully ceased. This amounted to approximately €180,000.

Ian and Maeve accepted this outcome in full and final settlement of their complaint.