Case study Sports accident – insurer declines claim

What happened

Ms H, a 42-year-old chemist, plays volleyball in her free time. During a training game she fell and injured her shoulder. The accident insurance said the claim wasn’t covered because its medical examiner didn’t think her health problems were caused by an accident. According to the examiner they were degenerative, i.e. an illness rather than an accident.

Ms H complained to the Ombudsman Office, because she believes the accident insurer should pay for the treatment of her shoulder problems that emerged after her fall.

Outcome of Ombudsman investigation

The Ombudsman Office looked at the evidence provided by Ms H and recommended that she in a first step consult her doctor. If he concluded that her problems were due to the accident, he should justify this in writing. After having received the medical report from her doctor we contacted the insurer, who settled the claim.