Great Lakes Insurance UK Limited · DRN-6235305

The complaint Mr and Mrs D have complained about the way Greak Lakes Insurance UK Limited (‘Great Lakes’) handled their medical emergency whilst abroad. What happened Mr and Mrs D had a travel insurance policy, underwritten by Great Lakes. They went abroad when unfortunately, Mr D had a skiing accident and attended hospital. They contacted Great Lakes and asked it to approve knee surgery and paid some costs upfront to the treating facility. Great Lakes did provide its authorisation for the surgery to go ahead but Mr D’s knee was too swollen for surgery and so the operation couldn’t go ahead. Mr and Mrs D returned to the UK. Mr and Mrs D say Mr D was unable to have his surgery abroad due to Great Lakes’ delay and they’re unhappy with the lack of assistance that was offered to them for their repatriation. They complained to Great Lakes and unhappy with its response, referred their complaint to the Financial Ombudsman Service. Our investigator looked into the complaint and found that overall, Great Lakes had provided appropriate assistance but it could have sent the guarantee of payment (GOP) to the hospital sooner than it did. And for the resulting distress and inconvenience, she recommended Great Lakes pay £250. Great Lakes agreed to the recommendation but Mr and Mrs D did not. In summary, they hold Great Lakes responsible for the lasting effects of Mr D’s injury and have asked for an Ombudsman’s decision. And so the case has been passed to me. 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. Having done so, I agree that Great Lakes handled matters appropriately except for the delay in sending the GOP. For this, I think the £250 recommended is fair and reasonable. I’ll explain why. Firstly, I'd like to say I am really sorry to hear of Mr D’s accident and the circumstances which led to this claim. All reference to Great Lakes includes any agents acting on its behalf. The relevant rules and industry guidelines say an insurer should handle claims promptly and fairly. And shouldn't unreasonably reject a claim.

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The background to this matter is well known to both parties. So I won’t repeat the facts here again. Instead I will focus on what I consider to be key to my conclusions. The starting point is the policy terms and conditions which make up the contract of insurance between Mr and Mrs D and Great Lakes. I will summarise any relevant terms under the below headings. I have set out the crux of the complaint and the key complaint points which have been made to Great Lakes and investigated, as set out by the investigator. Any complaint points following the final response letter dated 2 June 2025 have not been considered in this investigation. GOP for emergency surgery • The policy provides cover for emergency medical and repatriation expenses. Treatment in a private hospital is not covered unless there are no suitable public or state facilities available. The policy confirms it is travel insurance and not private medical insurance. The policy doesn’t cover treatment that can wait to be carried out after repatriation. And reciprocal health agreements must be used in the first instance. • Following Mr D’s accident, Mrs D contacted Great Lakes at around 3pm for authorisation for emergency surgery. Great Lakes approved the surgery on the following day at around 3pm, 24 hours later. The surgery had been booked for 5:30pm but due to swelling in Mr D’s knee, it couldn’t go ahead. Mr and Mrs D say had Great Lakes approved the surgery earlier, they could have had the surgery before Mr D’s knee had swollen. • I’ve carefully considered what Mr and Mrs D say and even if I agree that Great Lakes could have acted sooner, there is no evidence to show that the swelling in the knee wouldn’t have prevented Mr D from having the operation sooner. It isn’t clear when the swelling became worse or whether the treating hospital could have accommodated an earlier slot for the surgery. • Great Lakes are expected to deal with matters promptly, including GOPs, and I can see that the matter was referred to the underwriters due to the high cost and a query around why Mr D couldn’t be treated in a public hospital. This isn’t unusual and is in line with the policy terms. Great Lakes was entitled to ask whether there was a suitable public facility nearby and as there wasn’t, it agreed to cover the cost of the emergency surgery before the time of the rescheduled operation. • I note the surgery was recommended on the first evening but Great Lakes is entitled to carry out checks before agreeing cover. It isn’t unreasonable that the surgery on the first day wasn’t approved as Great Lakes needed to review the medical report before agreeing cover. However, from the timeline provided, Great Lakes could have communicated the agreement from the underwriters a few hours sooner than it did, by around mid-morning following the day of the accident. This would have minimised the ongoing stress and frustration caused to Mr and Mrs D as a result of chasing for a response. • For the delay in communicating the authorisation from the underwriter to the treating clinic, I agree that £250 compensation is fair and reasonable for the stress and impact. I don’t agree that the lasting effects of the inability to have the surgery due to swelling can be attributed to Great Lakes’ delay. Repatriation

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• Mr and Mrs D were also unhappy that Great Lakes didn’t assist with their repatriation. They had travelled in their motor home but there is no cover for motor homes under the terms of their policy. So Mr and Mrs D would always have needed to make alternative arrangements for the return of their motor home. Great Lakes explained this and offered to book appropriate flights with extra seats for Mr D. However, Mr and Mrs D emailed Great Lakes and confirmed they had decided to make their own return arrangements as they needed to bring their motorhome back too. So as Great Lakes did offer assistance with repatriation but Mr and Mrs D decided to make their own way home, I don’t uphold this aspect of the complaint. I wouldn’t expect Great Lakes to offer flights after receiving a clear email from Mr and Mrs D about making their own return arrangements. Follow up treatment • Mr and Mrs D wanted Great Lakes to cover the cost of Mr D’s surgery on a private basis in the UK or cover the costs to return abroad or pay the equivalent. However, the policy doesn’t provide private treatment and cover ended when Mr and Mrs D returned to the UK. Although Mr and Mrs D were taken to a private clinic by the ambulance, private hospital costs aren’t normally covered. Due to the distance between where Mr D had his accident and the closest public facility, Great Lakes agreed to approve the costs in the private clinic if Mr D was able to have the surgery whilst abroad. Unfortunately for Mr D, the treating doctors decided the surgery couldn’t go ahead due to swelling and so Mr and Mrs D returned home. Great Lakes are not under any obligation to fund the treatment in the UK or to provide the equivalent treatment costs. The policy only provides for emergency medical treatment costs to be covered whilst abroad, as set out in the terms. Overall, I am satisfied that Great Lakes provided appropriate advice and assistance despite the short delay in providing the GOP, for which some compensation is due. I can’t hold it responsible for Mr D’s injury, the lasting effects of the injury due to swelling, being unable to have the surgery abroad following approval from Great Lakes, or the lengthy NHS wait for surgery or treatment in the UK. My final decision For the reasons set out above, I partially uphold this complaint and direct Great Lakes Insurance UK Limited to pay Mr and Mrs D a total of £250 compensation. Under the rules of the Financial Ombudsman Service, I’m required to ask Mrs D and Mr D to accept or reject my decision before 24 April 2026. Shamaila Hussain Ombudsman

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