The High Court has sent Grzegorz Koczan’s complaint about absence from work benefits back to the Financial Services Ombudsman for review, finding that the Ombudsman had not properly examined the policy terms or whether they might be unfair.
Mr Justice Hogan delivered judgment on 1 November 2010 in Mr Koczan’s statutory appeal under the Central Bank Act 1942. The appeal concerned an Ombudsman decision that dismissed his complaint about a Bank of Ireland Life policy.
Mr Koczan, who had been employed as an operative with Kerry Foods, suffered a serious back injury at work on 31 July 2006. He had taken out a life assurance and critical illness policy in December 2005. The company said the policy lapsed after the last premium it received, dated 1 September 2006. It offered €825 for absence from work benefits, calculated at €165 a week for five weeks, with no benefit payable for the first four weeks of absence.
The Ombudsman had concluded that the company paid the correct benefit. On appeal, the company did not participate in the court proceedings. Mr Koczan argued that he understood the policy to work like motor insurance and that the key question was whether it was in force when his accident happened.
Justice Hogan said the Ombudsman had accepted the company’s account of the policy lapse without closely analysing the wording of the relevant clause. He also found that the Ombudsman had not considered whether the policy terms or the company’s practice could be unreasonable, unjust or oppressive, even if the terms did allow the policy to lapse. The judge said the policy wording could be read as suggesting that benefits might continue while a fund remained, and that the Ombudsman should examine the issue in the first instance. He stressed that his judgment did not prejudge the outcome of that review.
The court upheld the Ombudsman’s findings on the other two issues. The policy’s critical illness cover applied to a specified list of illnesses that did not include back injuries. On delay, the court accepted that delays in supplying medical information, rather than the company, accounted for the delay in processing the claim.
The court set aside the Ombudsman’s finding on absence from work benefits and directed the Ombudsman to re-examine that part of the complaint in light of the judgment. It did not decide whether Mr Koczan was entitled to more benefits.