Private Health Insurance Decision Reference 2023-0275

Case OutcomeUpheld
Date07 December 2023
Subject MatterPrivate Health Insurance
Finantial SectorInsurance
Conducts Complained OfRejection of claim - waiting periods apply
Decision Ref:
Product / Service:
Private Health Insurance
Conduct(s) complained of:
Rejection of claim - waiting periods apply
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
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 -
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
The Complainants want the Provider to pay [the hospital]” invoice, as the First
Complainant’s “only income is an O.A.P pension”.
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.

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