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Hi All
I'm hoping someone on here may have some useful nuggets of information or guidance for me.
I raised a claim under my employers Group Personal Accident policy 3 years ago, the declined so I referred to FOS. The adjudicator upheld, however insurer referred to ombudsman who refused. Claim was in respect of the policy definition of the term "accident", without going into too much detail, the policy definition covered my injury, however insurers posited that this wasn't sufficient and cited 100 year old case law as to what they though "accident" meant. effectively rewriting the policy post event. After all why should the FOS apply the fair and reasonable test and good industry practice (surely published FOS cases count as good industry practice), when they can rely on 19th century case law!
I know that I cannot appeal an ombudsman decision, no matter how "bonkers" it is (a technical term :-) and am now considering my courses for action. As far as I am aware the only courses I have available are judicial review or breach of contract direct to insurer.
1) judicial review, A high risk approach given the real hurdle of proving one of the grounds, I believe I have grounds under bias (you should read his decision letter), irrationality (failed to follow published FOS technical guidance and two published cases on ombudsmans news) , reasonable expectation (the policy said it was covered, what happened to contract certainty?) and legality (failed to apply contra proferentem)
What I am looking for is basically precedent, does anyone know of any citable cases where a claimant has won on irrationality, or failure to apply contra proferentem? Indeed does anyone have any guidance of any sort?
2) Breach of contract claim. I am a bit stuffed here, policy is a group PA policy in the name of my employer. I am shown as an insured person, but not the assured. The policy contains a rights of third party's exclusion, and I'm pretty certain they will use that as a defence. I have found a few potential challenges and ways of getting round the doctrine of privity, though I am not sure I would bet my hat on them. The FCA handbook defines policy holder to include a person who is entitled to receive a benefit from an insurance policy, including on a contingent basis. Does anyone think I could use that definition to block the rights of third party's defence?
Any suggestions gratefully received, the sum in question is £100k, so I am not giving up lightly. My LE insurers won't back me citing disproportionate likely costs (thanks!) despite me having a formal legal opinion that puts likelihood of success at 60%
Alternatively, any solicitors out there who fancy taking a punt on a contingent fee basis?
Look forward to receiving some sage advice, and hopefully the "killer" precedent that will knock the FOS on its A**
Thanks
Adam
I'm hoping someone on here may have some useful nuggets of information or guidance for me.
I raised a claim under my employers Group Personal Accident policy 3 years ago, the declined so I referred to FOS. The adjudicator upheld, however insurer referred to ombudsman who refused. Claim was in respect of the policy definition of the term "accident", without going into too much detail, the policy definition covered my injury, however insurers posited that this wasn't sufficient and cited 100 year old case law as to what they though "accident" meant. effectively rewriting the policy post event. After all why should the FOS apply the fair and reasonable test and good industry practice (surely published FOS cases count as good industry practice), when they can rely on 19th century case law!
I know that I cannot appeal an ombudsman decision, no matter how "bonkers" it is (a technical term :-) and am now considering my courses for action. As far as I am aware the only courses I have available are judicial review or breach of contract direct to insurer.
1) judicial review, A high risk approach given the real hurdle of proving one of the grounds, I believe I have grounds under bias (you should read his decision letter), irrationality (failed to follow published FOS technical guidance and two published cases on ombudsmans news) , reasonable expectation (the policy said it was covered, what happened to contract certainty?) and legality (failed to apply contra proferentem)
What I am looking for is basically precedent, does anyone know of any citable cases where a claimant has won on irrationality, or failure to apply contra proferentem? Indeed does anyone have any guidance of any sort?
2) Breach of contract claim. I am a bit stuffed here, policy is a group PA policy in the name of my employer. I am shown as an insured person, but not the assured. The policy contains a rights of third party's exclusion, and I'm pretty certain they will use that as a defence. I have found a few potential challenges and ways of getting round the doctrine of privity, though I am not sure I would bet my hat on them. The FCA handbook defines policy holder to include a person who is entitled to receive a benefit from an insurance policy, including on a contingent basis. Does anyone think I could use that definition to block the rights of third party's defence?
Any suggestions gratefully received, the sum in question is £100k, so I am not giving up lightly. My LE insurers won't back me citing disproportionate likely costs (thanks!) despite me having a formal legal opinion that puts likelihood of success at 60%
Alternatively, any solicitors out there who fancy taking a punt on a contingent fee basis?
Look forward to receiving some sage advice, and hopefully the "killer" precedent that will knock the FOS on its A**
Thanks
Adam
