AmTrust Specialty Limited · DRN-6185539

The complaint Mr S complains about the way AmTrust Specialty Limited dealt with a claim he made on his legal expenses insurance policy and about the service AmTrust provided to him, including its legal helpline. Where I refer to AmTrust Specialty Limited, this includes its agents and claims handlers acting on its behalf. What happened In October 2024 Mr S took out legal expenses insurance, underwritten by AmTrust. The cover started on 21 November. In December 2024 Mr S made a claim on the policy for a clinical negligence case but the claim was declined. AmTrust said the events that led to the claim had happened before the policy started so they were not covered. Mr S complained about the decision to decline his claim. He was unhappy his claim had not been assessed by a qualified solicitor, and was also unhappy with the way calls he made to the legal helpline were dealt with. When he referred the complaint to this Service, our investigator said the claim had been dealt with fairly, and the helpline had provided the service it was designed for. Mr S disagrees and has requested an ombudsman’s decision. He has provided detailed comments. I won’t set them out in full but the key points include: • His claim concerned ongoing negligence, which continued after the policy started. Given the complex nature of the ongoing clinical disputes, the blanket application of the exclusion was unfair. • It wasn’t reasonable to have a complex case assessed by administrative staff without referring it to solicitors for an assessment. Claims handlers would not be able to assess the legal nuances of an ongoing breach of a legal duty. • His complaint about the legal helpline is not a disagreement about a legal opinion – it’s about the failure to provide the service with reasonable care and skill in line with the Consumer Rights Act. The adviser misunderstood the nature of his call and admitted they lacked experience in this type of clinical negligence claim. What I’ve decided – and why I’ve considered all the available evidence and arguments to decide what’s fair and reasonable in the circumstances of this complaint. I’ve considered Mr S’ comments carefully. I appreciate how important this is for him but, while it will be disappointing for him, I’m not upholding the complaint for the following reasons.

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The claim The relevant industry rules and guidance say insurers must deal with claims promptly and fairly and not unreasonably reject a claim. The starting point when deciding whether the claim was dealt with fairly is the policy terms; these set out the terms of the insurance contract agreed between Mr S and AmTrust. There is cover for clinical negligence claims, but this is subject to the policy terms and conditions. The policy terms say cover is provided where “The insured event takes place in the period of insurance…” The Insured event is defined as: “The incident (or the start of a transaction, or series of incidents), which may lead to a claim (or claims) being made under the terms of this insurance.” There is also an exclusion which says there is no cover where “You should have known when buying this insurance that the circumstances leading to a claim under this insurance already existed”. Terms like this are not unusual in legal expenses policies. Insurance is generally provided to protect against the risk of something happening in the future, not something that has already started before someone takes out the policy. AmTrust has appointed claims handlers. It’s entitled to do this, and the policy documents say the cover is managed by the claims handlers on behalf of AmTrust, who remain responsible for the claims handlers’ actions. The claim was declined because it arose out of events that happened before the policy started in November 2024. In his claim, Mr S explained that he had been referred to a specialist team in 2022 and put on a waiting list. In 2023 he complained about the way he was dealt with, including the lack of a formal diagnosis and support. After raising further concerns, he made another complaint in July 2024. He told the helpline he had exhausted the complaints process (including the ombudsman) and now wanted to issue a claim for clinical negligence. All of this happened before he took out legal expenses cover. Even if there was an ongoing dispute, it had started before he bought the policy and he was aware when he got the policy of the issues that led him to make a claim. There’s no cover in these circumstances. AmTrust’s claims handlers were able to decide this without the need for legal advice. Mr S says the claim should have been assessed by a qualified solicitor but that wasn’t required. These are not legal issues - it’s an insurance decision about when the incidents that led to the claim happened. Legal expenses policies don’t cover every type of legal action – cover is limited to the insured perils set out in the policy terms. When a claim is made, the insurer will first assess whether there is an insured event. If there is, they will then refer the claim to solicitors to assess whether the claim has reasonable prospects of success. Mr S hadn’t got to that stage. There’s no need for a legal referral if there is not an insured event. The legal helpline The legal advice helpline is provided by panel solicitors on behalf of AmTrust, so AmTrust is

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responsible for complaints about the helpline. But, while we can consider customer service issues about this, we can’t comment on the legal advice provided. Mr S made two calls. The first was about the clinical negligence claim. He was given general advice and told if he wanted to make a claim, they couldn’t assess that over the phone – he needed to submit the claim. The insurer would first check it was something that was covered by the policy and if it was, go on to arrange a legal assessment of the prospects of success. That was an accurate explanation of what would happen. The second call was about his ‘blue badge’ being removed. The adviser said this wouldn’t be covered by the policy, and they couldn’t confirm whether he was entitled to a badge. They gave some general advice, explaining how councils deal with this, and how to challenge a decision. It’s not for me to comment on the legal advice itself. Mr S says providing generic information does not amount to "reasonable care and skill" for a specialised legal helpline but the point of a helpline like this is just to provide general advice, based on the limited information that can be given in a phone call. Where that indicates there might be a claim that could be made on the policy, it can then be taken further – as happened with his clinical negligence claim. There may be some very limited circumstances where I could agree the advice was wrong – perhaps, for example, if the insurer accepts it was wrong or there is an opinion from someone suitably qualified to say the advice was obviously wrong. That’s not the case here. I’m satisfied the helpline provided the service it was intended to. My final decision My decision is that I don’t uphold the complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr S to accept or reject my decision before 27 March 2026. Peter Whiteley Ombudsman

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