Personal Accident Decision Reference 2025-0208

• Case Outcome: Rejected
• Year: 2025
• Reference: 2025-0208
• Date: 19 December 2025
• Subject Matter: Personal Accident
• Finantial Sector: Insurance
• Conducts Complained Of: Rejection of claim - pre-existing condition

Decision Ref:

2025-0208

Sector:

Insurance

Product / Service:

Personal Accident

Conduct(s) complained of:

Rejection of claim - pre-existing condition

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

The Complainant held a health insurance policy with the Provider (the "Policy").

The complaint concerns the Provider's refusal of the Complainant's claim for a hip

replacement procedure (the "Procedure") at a private hospital (the "Hospital"). The

Provider refused the claim on the basis that the procedure was to treat a pre-existing

condition which was subject to a two-year waiting period.

The Complainant’s Case

In the Complaint Form submitted to this Office, the Complainant explains that he amended

his healthcare policy with the Provider. He submits that the Provider is now refusing to

cover him and that he has an outstanding bill in the amount of €12,879.64 (twelve

thousand eight hundred and seventy-nine euros and sixty-four cents).

In support of his complaint the Complainant has submitted to this Office correspondence

between his legal adviser (the "Legal Adviser") and the Provider concerning the claim. This

correspondence contains the substance of the Complainant's case.

Within the correspondence the Legal Adviser states that the Complainant's Policy was

amended on 20 December 2017 to take effect on 22 January 2018. The Legal Adviser

- 2 -

/Cont’d…

states that there was a telephone call between the Complainant's wife and the Provider on

20 December 2017 regarding these changes to the Policy. During this call the

Complainant's wife is said by the Legal Adviser to have informed the Provider that the

Complainant, due to his family history, would likely require orthopaedic surgical

intervention. The Legal Adviser asserts that the Provider was therefore clearly aware that

the Complainant would require surgery in the future.

The Legal Adviser explains that the Complainant's wife contacted the Provider on 6

February 2019 to alert it to the fact that the Complainant would be undergoing the

Procedure on the following day: 7 February 2019.

The Legal Adviser states that the Complainant has been contacted directly by the Hospital

at which the Procedure was carried out in relation to payment for the Procedure. The

Legal Adviser asserts that the Complainant is not obliged to pay¸ "as they have cover with

your Company." The Legal Adviser calls on the Provider to "discharge the monies due and

owing as per the terms of our clients (sic) policy." The Legal Adviser also states that the

Complainant and his wife are "considering their position in relation to the Breach of

Contract by [the Provider] and the upset and distress caused to them."

In support of his complaint, the Complainant has also submitted two invoices. One is from

the Hospital in the amount of €11,552.64 (eleven thousand five hundred and fifty-two

euros and sixty-four cents). The second is for the services of a consultant orthopaedic

surgeon (the "Consultant Surgeon") for the conduct of the Procedure in the amount of

€1,227 (one thousand two hundred and twenty-seven euros).

By way of resolution, the Complainant seeks the following:

"Payment of the outstanding invoices issued from the [the Provider] in the amount

of €11,652.64 and [the Consultant Surgeon] in the amount of €1,227.00".

The Provider’s Case

The Provider states that the Complainant's wife made changes to the Policy on 20

December 2017. It states that she was entitled to do so at that time as his spouse. It states

that it issued policy documentation to the Complainant on 21 December 2017 and the

upgrades took effect on 22 January 2018. The Provider states that from this date the

Complainant was subject to the "upgrade rule for pre-existing conditions until 22 January

2020".