Private Health Insurance Decision Reference 2019-0265

• Case Outcome: Partially upheld
• Subject Matter: Private Health Insurance
• Reference: 2019-0265
• Date: 02 August 2019
• Conducts Complained Of: Disagreement regarding Settlement amount offered,
• Finantial Sector: Insurance

Decision Ref:

2019-0265

Sector:

Insurance

Product / Service:

Private Health Insurance

Conduct(s) complained of:

Disagreement regarding Settlement amount offered

Outcome:

Partially upheld

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

Background

This complaint concerns a health insurance policy, and relates to the Complainant’s claim

under the policy for orthotic expenses, namely insoles and boots, for the sum of €554.99,

incurred between November 2017 and January 2018.

The complaint is that the Provider has incorrectly applied the outpatient excess to the

Complainant’s claim in January 2018 resulting in the Complainant not receiving any refund

of expenses paid for orthotic insoles and boots, and that it has proffered below-par

customer service throughout.

The Complainant’s Case

The Complainant purchased orthotic insoles on 7 December 2017 for the sum of €165. She

also bought orthotic boots on 20 November 2017 and 4 January 2018 for the sums of

€239.99 and €150, respectively, and submitted a claim for these expenses to the Provider

in January 2018 with the receipts for same as requested by the Provider.

Following the repudiation of her claim, the Complainant raised a complaint with the

Provider in February 2018. She contends that she was aware of an excess on her policy of

€200. The Complainant maintains that the maximum benefit she “can claim for orthotics,

under Medical and Surgical Appliances is 50% up to € 200.00” and that she has “spent in

total €554.99. The excess is €200.00. Surely then [she is] entitled to €200 from the

remaining balance of €334.99?” The Complainant states that not receiving any

reimbursement “makes little sense to [her]”.