From time to time complaints about private healthcare involve insurance companies and their policies and levels of service.

Many of those complaints arise because a patient may not have followed the claims procedure laid down by the insurer. But apart from these difficulties, one of the most common complaints is triggered by an insurer refusing to cover the cost of a particular consultant, test or procedure.

The majority of private medical insurers will differentiate between an “acute” and a “chronic” condition and only reimburse for the former. A dispute can also arise when a patient reaches a certain point in their illness and the insurers stop paying for treatment because a condition is deemed to be ‘chronic’ or perhaps if there is no hope of recovery. As the Terms and Conditions of private medical insurance policies vary widely between companies (and every insurance company also has a wide range of different policies on offer) any complaint must be based on the precise terms and conditions which apply.

There are sometimes concerns about insurers choosing consultants for patients on cost grounds rather than on medical need and suitability. In the vast majority of cases your GP will give you the names of a consultant who is the best person to give you specialist care appropriate to your clinical needs. There should be no choice made, for example, on the grounds that a different consultant is cheaper for the insurer.

Again a patient or should try to resolve a dispute with an insurer in the first instance. Most problems are resolved to the satisfaction of both sides. If a solution cannot be achieved and you believe after exhaustive efforts, that your insurer is in the wrong, you can take two courses of action. All private medical Insurers are regulated by The Financial Conduct Authority (FCA) and answerable also to the Financial Ombudsman.  Have a look at our news item on the new FCA

The Financial Conduct Authority has guidance on how to complain and you can find it online here:

For individual patients and small firms with a maximum of 10 employees and small charities, the Financial Ombudsman Service (FOS) is there to help those who feel they have tried to get a settlement be negotiating directly with insurers but have failed to do so.

The FOS has an excellent advice service and if all else fails will take up a patient’s complaint and investigate. Have a look at our page reporting some recent findings relative to private medical insurance.

If the Financial Ombudsman Service finds in favour of the patient who has made the complaint, it has the power to put the patient in a financial position that he or she would have been in if nothing had gone wrong in the fist place.

FOS can make a financial award up to £100,000 and order the insurance company to apologise and ensure the same thing cannot happen again.

The Financial Ombudsman Service guide to patients who wish to make a complaint can be found at:

Finally, some patients, understandably, become frustrated with the complaints process and the time taken to deal with them and so they go to the media with their experiences. This can work both for and against the interests of the patient and we would advise patients to follow the routes outlined above in the first instance.


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