In August 2024, Edmund suffered an injury to his neck and spine. He underwent an operation and made a claim under his trauma policy. The claim was rejected on the basis that the operation was not for a condition covered by the policy. The Insurance and Financial Services Ombudsman Scheme upheld the decision to decline the claim.

Edmund complained that the bank sold him an incorrect policy because it did not cover the neck and spine injury he sustained. He said the bank told him the trauma policy would cover all spinal injuries.

Our investigation

Edmund told us he and the bank’s insurance manager discussed the coverage provided under the trauma policy. He recalled that she read out information about the types of conditions covered, including cancer, stroke and loss of limb. This was consistent with the recollection of the insurance manager, who said she remembered telling Edmund about the various insurance policies available through the bank. Edmund also recalled her going through everything with him, including income protection insurance. He told us he didn’t proceed with income protection insurance because he couldn’t afford it. He opted instead for trauma cover.  

Edmund said she told him he would be covered if he had an accident that left him in a wheelchair or had a spinal injury, including one from which he made a full recovery. The insurance manager said she did not recall mentioning such specifics. She added that she would not have given any assurances about policy coverage in the event of a full recovery because such a decision was for the policy’s underwriter. 

The insurance manager followed up the meeting with a statement of advice recording the information Edmund had given about his financial situation and personal risk goals. The statement included a benefit sheet for the trauma policy. It listed conditions covered by grouping, such as cancer, heart, paralysis and loss of function. 

The policy documents clearly listed – and described – all the conditions for which cover would be provided under the trauma policy. We therefore found the bank did not mislead Edmund about the cover provided by the trauma policy.  

We also did not consider the bank sold Edmund a policy that was unsuitable for him. The sale process was thorough and appropriate. The bank gathered information about Edmund’s needs, gave him clear information about the policies available, explained the exclusions, accurately recorded his financial situation and personal risk goals, and made an appropriate recommendation. Edmund chose to take out a life insurance policy and a trauma policy. 

Outcome

We did not uphold Edmund’s complaint.