Critical & Serious Illness Decision Reference 2023-0262

• Case Outcome: Rejected
• Year: 2023
• Date: 29 November 2023
• Reference: 2023-0262
• Subject Matter: Critical & Serious Illness
• Finantial Sector: Insurance
• Conducts Complained Of: Rejection of claim – partial rejection

Decision Ref:

2023-0262

Sector:

Insurance

Product / Service:

Critical & Serious Illness

Conduct(s) complained of:

Rejection of claim – partial rejection

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

The Complainant holds a Health Insurance Policy with the Provider. The complaint

concerns the Provider’s assessment of the Complainant’s request in July 2019, for the

preapproval of the cost of a neurosurgical procedure which the Complainant underwent in

an overseas medical facility. The policy period in which this complaint falls, is from 1 April

2019 to 31 March 2020.

The Complainant’s Case

The Complainant says that her treating clinician in Ireland referred her to an overseas

medical facility where, on 24 July 2019, she underwent a neurosurgical procedure not

available in Ireland for the treatment of [type redacted] disorders, at a cost of GBP

£67,425.00 (sixty-seven thousand four hundred and twenty-five Sterling Pounds), which

she calculates as amounting to €80,896.84 (eight thousand eight hundred and ninety-six

Euros and eighty-four Cents)

The Complainant says that in advance of undergoing this surgery, she had, from 25

January 2019, considerable telephone communications with the Provider in respect of the

funding for the procedure and that her first telephone call with it, in relation to his matter

was, as she submits in her letter of complaint to this Office dated 16 March 2020:

“…one of many whereby [Provider] did not demonstrate any form of reasonable

assistance to me and in fact were obstructive to me accessing funding for my

treatment”.

- 2 -

/Cont’d…

The Complainant says she completed an Overseas Pre-approval Form to the Provider on

10 July 2019, seeking for it to preauthorise cover for the cost of the surgery under the

Elective Overseas Referral benefit included in her Health Insurance Policy.

The Complainant says that the Provider informed her on 18 July 2019 that it had pre-

authorised the amount of €23,668.48 towards the cost of her overseas surgery.

The Complainant says that when, during a telephone call with the Provider on 18 July 2019

she expressed her dissatisfaction with the pre-authorised amount, the Agent advised her

that the shortfall was something she could discuss with the HSE.

The Complainant says that following subsequent engagement with her Representative, the

Provider advised on 22 July 2019 that it had increased the pre-authorised amount to

€31,122.00 (thirty one thousand one hundred and twenty-two Euros). The Complainant, in

her letter of complaint to this Office dated 16 March 2020, submits, among other things,

that:

“In reviewing my application [Provider] restricted the payment for overseas

treatment costings to award me just [€31,122.00] even though my policy allows for

up to €65,000 in respect of overseas treatments. This award is unfair as [Provider]

applied costings from Ireland to a treatment which is not available in Ireland … It is

my contention that [Provider] may not in good faith use a notional cost for a

treatment which is specifically not available in Ireland as a basis for a

reimbursement to a patient accessing a treatment abroad … It would be

understandable in a situation where a treatment is available in Ireland…that

[Provider] would limit the level of reimbursement to that which [Provider] would

have incurred if the patient were accessing the healthcare in Ireland. But in a case

where the patient cannot access the treatments in Ireland then the provision of the

policy to cover necessary healthcare should apply in full.

[Provider] assigned a value of €31,122 to the cost of the treatment in the UK

effectively ensuring I could not access the healthcare which had an actual cost of in

excess of £67,425”.

The Complainant says that because the Provider was only willing to contribute €31,122.00

towards the GBP £67,425.00 cost of her overseas surgery, and because it was not willing

to make payment directly to the overseas medical facility, she could not have proceeded

with the surgery on 24 July 2019 as scheduled, without the financial assistance of the HSE.

The Complainant sets out her complaint in the FSPO Complaint Form she completed, as

follows:

“Failure of [Provider] to fund treatment in the UK which is not available in Ireland.

The funding awarded was just over €31,000 but the treatment is £65,000 stg.

[Provider] refused to pay [the medical facility overseas] directly, risking my ability

to access the treatment.