Private Health Insurance Decision Reference 2025-0164

• Case Outcome: Rejected
• Year: 2025
• Reference: 2025-0164
• Date: 10 November 2025
• Subject Matter: Private Health Insurance
• Finantial Sector: Insurance
• Conducts Complained Of: Rejection of claim

Decision Ref:

2025-0164

Sector:

Insurance

Product / Service:

Private Health Insurance

Conduct(s) complained of:

Rejection of claim

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

Background

The Complainant is covered by a health insurance policy (the "Policy") issued by the

Provider. The Complainant attended a consultation with a consultant registered with the

Provider (the "Consultant") regarding a surgical procedure (the "Procedure") and paid a

consultation fee of €350.00 (three hundred and fifty euro). The Complainant says that the

Consultant informed her that the Consultant did not accept insurance payments for the

Procedure. Consequently, the Complainant seeks payment of the consultation fee from

the Provider.

The Complainant’s Case

The Complainant details that she needed an operation and that she "used the list of [the

Provider's] approved consultants and found a doctor that is on that list." The Complainant

explains that she contacted the Consultant's secretary before her first consultation to

confirm that the operation could be performed by the Consultant and that it could take

place in a hospital approved by the Provider.

The Complainant submits that during the medical consultation, the Consultant, "agreed

that it is a medically necessary procedure" but that the Consultant, "told me that she [the

consultant] does not take insurance payments for this operation."