Lloyd’s Australia has won a travel cover dispute after its investigator was unable to substantiate a policyholder’s claim that medical costs were incurred when his daughters fell ill.

The traveller held a policy covering emergency medical expenses, valid from February 1-18 2022. On February 21 he lodged two claims for treatment to his two daughters for a malaria-like illness.

Lloyd’s accepted both claims but later told the man concerns had been raised. 

It was advised of previous claims with three different insurers that were similar in nature and in some cases were declined because of fraud. The father did not dispute these outcomes.

Lloyd’s appointed an investigator and later declined both claims, saying the father had not provided sufficient evidence to validate them.

“Based on the information, the insurer submits the complainant’s claim history significantly diminishes the likelihood of the reported events,” a determination by the Australian Financial Complaints Authority says.

AFCA has upheld the claim rejection, saying Lloyd’s is entitled to refuse payment. “The information regarding previous claims raises concerns regarding the credibility of the complainant and these current claims,” it says.

The investigator attended the clinic where treatment was said to have taken place, but was advised the doctor in charge could be contacted by phone only. The clinic was in a state of disrepair and appeared unused, and it would not provide copies of licences and credentials to operate, as required by authorities in that country. 

The signage at the clinic was different to the name on documents provided by the father, and it was located 20 kilometres away from the complainant’s accommodation.

The investigator spoke with the accommodation provider, who confirmed the man’s stay but would not provide supporting information. AFCA says the investigation raised “significant concerns as to the credibility of the complainant’s claims”.

“The complainant has the onus ... to establish that the claims are consistent with the other known and confirmed evidence and that the claims are credible,” the authority’s adjudicator said. “The investigator was unable to substantiate the costs incurred.

“Based on all the exchanged information, I am not satisfied the complainant has established the expenses were incurred.”

See the ruling here.