When you have tried everything to get your insurer to see your point of view and failed, you can refer to the Financial Ombudsman Service (FOS). Interestingly, the FOS states that “Complaints about health and medical insurance can be some of the most sensitive and hardest-fought that we see – as well as some of the most challenging to resolve.”

If you click here, you will see a number of cases brought to the FOS. In six of these eight the Ombudsman found in favour of the complainant. Here are the summaries.

  • 117/1 – consumer complains that insurer has rejected private medical insurance claim – on grounds that second operation is a separate procedure
  • 117/2 – consumer complains that insurer has rejected claim made under group policy – on grounds that treatment is “unproven”
  • 117/3 – consumer complains that restriction on cover for caesarean sections wasn’t made clear in private medical insurance policy
  • 117/4 – consumer complains that insurer has rejected critical illness claim on grounds that operation happened after policy had expired
  • 117/5 – consumer complains that private medical insurance doesn’t cover pre-existing condition – and that it has been mis-sold
  • 117/6 – consumer’s husband complains that insurer has rejected critical illness claim – because the consumer didn’t live long enough after diagnosis
  • 117/7 – consumer complains that private medical insurance claim has been rejected – because insurer says there was no “acute flare up” of a “chronic” condition
  • 117/8 – consumer complains that insurer has stopped paying income protection benefit – on grounds that consumer is no longer incapacitated

Do look at the full reports on the FOS website.

Incidentally, PPF has been following one case with special interest. The complainant works in the private healthcare sector. His issue is to do with continuing treatment for Age-related Macular Degeneration (AMD). We will keep you posted!

 

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