Private Health Insurance Decision Reference 2020-0280

Case OutcomeRejected
Subject MatterPrivate Health Insurance
Reference2020-0280
Date25 August 2020
Conducts Complained OfRejection of claim - pre-existing condition,Disagreement regarding Medical evidence submitted
Finantial SectorInsurance
Decision Ref:
2020-0280
Sector:
Insurance
Product / Service:
Private Health Insurance
Conduct(s) complained of:
Rejection of claim - pre-existing condition
Disagreement regarding Medical evidence
submitted
Outcome:
Rejected
LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN
The Complaint concerns a health insurance policy held by the Complainants.
The Complainants’ Case
The first Complainant was admitted to a private hospital and underwent surgery for major
spinal injury on the 6 December 2018. The Complainants state that they were informed that
their health insurance claim was rejected “on the basis that the symptoms were present prior
to my increasing on 8th February 2017”, as there was a two-year waiting period on the
Complainants’ policy before pre-existing conditions would be covered.
The Complainants attest that they were advised that they were covered for the surgery, as
they “had a telephone conversation with an agent in the week starting 23rd July 2018
where they were assured that I was covered as onset of symptoms was after our increased
benefits in February 2017”.
The Complainants stated that they received copies of the correspondence between their
medical practitioners alongside the Final Response Letter from their Provider. In these
documents, the First Complainant contends that the correspondence between these
specialists contains significant inaccuracies, in particular my age being five years older and
duration of symptoms as 3-4 years”. The Complainants state that “this discrepancy was then
repeated and perpetuated in subsequent correspondence”.

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