In this recent judgment the insurer rejected the life policy claim of the executor of the deceased estate relying on an exclusion in the policy that liability would not arise where death resulted from a condition that pre-existed the existence of the policy if that death occurred before the expiration of twelve months from the date of commencement of the policy.
The Ombudsman dismissed the claim refused leave to appeal to the Appeal Tribunal. The executor sought to review that refusal.
The court held that the rules of the relevant Ombudsman provides that a determination made by the Ombudsman was binding on the subscribing member so that the applicant could not disregard the final determination and seek payment from the court without first seeking for that to be reviewed, set aside and substituted.
The executor could also not rely on the Promotion of Administrative Justice Act to review the refusal because the Ombudsman’s decision did not constitute an administrative action as defined under that legislation and nor was the Ombudsman an organ of state.
The court did hold however that the decision was reviewable at common law and granted leave to appeal to the Appeal Tribunal because the applicant had prospects of success on appeal.
The judgment has been criticised on the basis that there was no dispute of fact and it the date on which the insurance contract was concluded was clear and a decision could have been made on the claim.