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Determination
Case number | 1047905 |
Financial firm | Lloyd's Australia Limited |
Case number: 1047905 16 May 2024
The complainant held a travel insurance policy with the financial firm (insurer) for travel from 1 February 2022 to 18 February 2022.
On 21 February 2022, the complainant lodged two claims to recover costs incurred for the treatment of both his daughters for illnesses. Due to the information provided, and the previous claim history, an investigator was appointed to investigate the circumstances of the claims.
On 7 March 2023, the insurer advised of acceptance of both claims. However, subsequently, the insurer notified the complainant of concerns raised in the final audit of the payment of the claims.
The insurer declined both claims because of the information obtained from three different insurers and says the cause of the claims and the circumstances are not coverable under the terms of the policy and the complainant has not provided sufficient evidence to unequivocally validate his claims.
No. Based on the exchanged information, I am not satisfied the complainant has established valid claims.
Yes. The insurer is entitled to refuse payment of the claims.
The outcome is fair as the complainant has not established a loss covered under the policy.
This determination is in favour of the insurer.
The insurer is not required to take any action.
The complainant’s held a travel insurance policy, purchased on 1 February 2022, for coverage from 1 February to 18 February 2022.
The policy provides cover for medical emergency expenses whilst travelling. To establish cover, the complainant is required to provide evidence that he has suffered a loss covered under the terms and conditions of the policy. The policy states the insurer is not under obligation to make payment without proof of a claimable event.
On 21 February 2022, the complainant lodged two claims for ongoing costs for treating his two daughters with Malaria-like illness. Due to the circumstances and the complainant’s previous claim history with similar claims involving similar illnesses with his daughters, the insurer decided to investigate the claim.
As part of the assessment of the claim, the insurer appointed an investigator. The investigator attended the medical clinic where treatment was said to have taken place. When the investigator asked to speak with the doctor in charge, it was advised the doctor was only contactable over phone and would not meet with the investigator.
The investigator observed the clinic was in a state of disrepair and appeared unused. Further, the clinic would not provide copies of licences and credentials to operate a medical clinic as required by the relevant country. The investigated noted the signage at the clinic was different to the name on the documents provided by the complainant. The clinic was located 20kms from the complainant’s accommodation and located away from the main road.
The investigator spoke with the accommodation provider, who confirmed the complainant’s stay, however would not provide information to show this. Rather, confirmed the receipt provided by the complainant.
In my view, the concerns referred to by the insurer raise significant concerns as to the credibility of the complainant’s claims.
The complainant has the onus to establish that the claims are covered under the terms and conditions of the policy. This onus extends to establish that the claims are consistent with the other known and confirmed evidence and that the claims are credible.
Having consideration the available information, I am satisfied the investigator was unable to substantiate the costs incurred.
The insurer did accept the claims and advised the complainant. However, the insurer was then advised of previous claims with three different insurers. These claims were similar in nature, and in some cases the claims were declined because of fraud. The complainant did not dispute these outcomes.
Based on the information, the insurer submits the complainant’s claim history significantly diminishes the likelihood of the reported events. On this basis the insurer declined the claim.
I agree, the information regarding previous claims raises concerns regarding the credibility of the complainant and these current claims.
It is accepted insurance law that the complainant carries the initial onus to establish a loss which is covered by the terms and conditions of the policy.
Based on all the exchanged information, I am not satisfied the complainant has established the expenses were incurred.
As a result, I am not satisfied the complainant has established a claim within the terms of the policy.
I am satisfied the insurer is entitled to refuse payment of the claim in accordance with the terms and conditions of the policy.
The policy wording is clear. The policy states the complainant must provide evidence that he has suffered a loss under the terms and conditions of the policy. The insurer is under no obligation to make payment without this.
There is clear evidence the complainant has not met his policy obligations in providing evidence that he has suffered a loss under the terms and conditions of the policy. I am satisfied the complainant has not established a valid claim. Therefore, the insurer is entitled to refuse payment of the claim.
The outcome is fair as the complainant has not established a loss covered under the policy.
AFCA has determined this complaint based on what is fair in all the circumstances, having regard to:
The respective parties have completed a full exchange of the relevant information, and each party has had the opportunity to address any issues raised. We have reviewed and considered all the information the parties have provided.
While the parties have raised several issues in their submissions, we have restricted this determination to the issues that are relevant to the outcome.
AFCA is not a court of law. We do not have the power to take or test evidence on oath, or to require third parties to give evidence.
When we assess complaints, we consider:
We give more weight to documents created at the time the events occurred. If there are no relevant documents, we will decide what most likely occurred based on the available information.
If there are conflicting recollections and these are evenly weighted, we may find that a claim cannot be established.
