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ombudsman news

issue 24

January 2003

ask ombudsman news - your questions answered

timeliness targets

How long does the ombudsman service take to consider and resolve complaints-

This largely depends on whether the customer and the firm both agree - at an early stage - to any recommendation or informal settlement that we may suggest - or whether either party requests the next, more formal stage of the process. The more formal stage includes detailed investigations and a full appeals process. It could involve seeking views and information from a range of experts and other people outside the ombudsman service. Obviously, this will take time, not least because some of those we need to contact may not respond to our enquiries as quickly as we would like.

In the plan & budget we published recently, we reported that our new targets are to close 45 percent of cases within three months and 80 percent of cases within six months. We aim to have closed 90 percent of cases within 9 months.

On average, we resolve around 45 percent of complaints at the early stage. 40 percent go on to the stage that requires an investigation and a formal report setting out our recommendations. Only about 15 percent of complaints require an individual final decision by an ombudsman. However ombudsmen are also involved indirectly at all stages, to make sure that their approach to different types of complaint is followed consistently at all times.

Between a third and a half of the cases where ombudsmen make formal final decisions are decided wholly or partly in the consumer's favour.

too ill to work - can firm refuse policy pay-out-

Can a firm refuse to pay benefits under an income protection policy simply because the policyholder's doctors can't diagnose precisely what is wrong- The doctors that my client consulted have all concluded that he is too ill to continue with his former occupation. However, the firm won't pay up. I can find nothing in the policy that says a clear diagnosis must have been reached before the claim is valid.

In some circumstances, the fact that no agreed physical causes can be found for a patient's symptoms might cast doubt on the genuineness of their condition.

But the lack of a clear diagnosis does not, in itself, demonstrate that the firm should reject the claim. Indeed, even if the doctors treating the patient are at a loss to explain his condition, providing they agree that it prevents him from continuing with his former occupation, then the lack of a diagnosis should not affect the claim's validity.

(for more on insurance disputes involving health, click here)

Walter Merricks, chief ombudsman

ombudsman news gives general information on the position at the date of publication. It is not a definitive statement of the law, our approach or our procedure.

The illustrative case studies are based broadly on real-life cases, but are not precedents. Individual cases are decided on their own facts.