Private Health Insurance Decision Reference 2023-0275

• Case Outcome: Upheld
• Year: 2023
• Date: 07 December 2023
• Reference: 2023-0275
• Subject Matter: Private Health Insurance
• Finantial Sector: Insurance
• Conducts Complained Of: Rejection of claim - waiting periods apply

Decision Ref:

2023-0275

Sector:

Insurance

Product / Service:

Private Health Insurance

Conduct(s) complained of:

Rejection of claim - waiting periods apply

Outcome:

Upheld

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

This complaint concerns the Complainants’ health insurance policy that was incepted with

the Provider on 5 November 2013.

The First Complainant made two claims on the insurance policy, after he was admitted to a

private hospital for treatment on 28 August 2018 and on 15 October 2018. The Provider

refused to cover the claims under the policy.

The Complainants’ Case

The Complainants say that the First Complainant had health insurance with another provider

from 1990 to 2010. At that point, the First Complainant had a break in cover, until the First

and Second Complainants incepted a new joint policy with the Provider on 5 November

2013.

The Second Complainant contacted the Provider on 27 August 2018, to enquire about their

cover. On 28 August 2018, the First Complainant was admitted to the private hospital until

he was discharged some 10 days later, on 7 September 2018.

On 15 October 2018, the First Complainant underwent further medical treatment in the

same private hospital and was discharged on 23 October 2018.

The Complainants were contacted on 19 December 2018 by the Provider, seeking

information regarding their previous health insurer. The Complainants confirmed that there

had been a “3-year gap in cover between 2010 and 2013”. The First Complainant says in the

Complaint Form that the treatment received in August 2018 was for a “previous condition”

and that he was “10 weeks short of the 5-year waiting period”.

- 2 -

/Cont’d…

The Provider’s Case

The Provider submits that the information it received “noted that [the First Complainant]

had symptoms of [his] condition since 2004, making this a pre-existing condition”.

The Provider says that at the time of both claims, the first Complainant had not served the

required 5 year waiting period, to be covered by the policy for the pre-existing condition.

The Provider contacted the Complainants again in January 2019 seeking confirmation of

medical insurance cover before 5 November 2013. The Complainants confirmed that they

did not have medical insurance cover between 7 November 2010 and 5 November 2013.

The Provider, “having reviewed the file” in January 2019, concluded that the Complainants’

first claim was declined correctly. In respect of the Complainants’ second claim, the Provider

concluded that:

“as this admission was connected to the prior admission in August, the claim was

denied due to the same reasons, the pre-existing waiting period was not served.”

The Complaint for Adjudication

The complaint is that the Provider wrongfully declined the Complainants’ claims for the cost

of hospital in-patient treatment, which the First Complainant received in August – October

2018.

The Complainants want the Provider to “pay [the hospital]” invoice, as the First

Complainant’s “only income is an O.A.P pension”.

Decision

During the investigation of this complaint by this Office, the Provider was requested to

supply its written response to the complaint and to supply all relevant documents and

information. The Provider responded in writing to the complaint and supplied a number of

items in evidence. The Complainants were given the opportunity to see the Provider’s

response and the evidence supplied by the Provider. A full exchange of documentation and

evidence took place between the parties.

In arriving at my Legally Binding Decision, I have carefully considered the evidence and

submissions put forward by the parties to the complaint. Having reviewed and considered

the submissions made by the parties to this complaint, I am satisfied that the submissions

and evidence furnished did not disclose a conflict of fact such as would require the holding

of an Oral Hearing to resolve any such conflict. I am also satisfied that the submissions and

evidence furnished were sufficient to enable a Legally Binding Decision to be made in this

complaint without the necessity for holding an Oral Hearing.