Private Health Insurance Decision Reference 2026-0018

• Case Outcome: Rejected
• Year: 2026
• Reference: 2026-0018
• Date: 12 February 2026
• Subject Matter: Private Health Insurance
• Finantial Sector: Insurance
• Conducts Complained Of: Claim handling delays or issues,Failure to process instructions

Decision Ref:

2026-0018

Sector:

Insurance

Product / Service:

Private Health Insurance

Conduct(s) complained of:

Claim handling delays or issues

Failure to process instructions

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

Background

This complaint relates to a Private Health Insurance policy (“The Policy”) which the

Complainant originally incepted with the Provider with effect from 1 January 2020.

The Complainant Case

The Complainant says the Table of Benefits, for the Policy, covers 50% of Consultant visits

with a one-euro excess applying.

The Complainant says he attended a Consultant Ophthalmologist on 23 June 2021 for a

pre-surgical consultation.

The Complainant states the receipt provided for the Consultation was a ““Consultant

Ophthalmologist” receipt - clearly visible in the response artefact”

The Complainant asserts the Provider has incorrectly categorised his visit to the Consultant

Ophthalmologist as a GP visit. As such, the Complainant says the visit is not claimable

under the Table of Benefits as a Consultant visit, which pays at a higher rate than a GP

visit.