Private Health Insurance Decision Reference 2022-0095

Case OutcomeRejected
Subject MatterPrivate Health Insurance
Reference2022-0095
Date15 March 2022
Finantial SectorInsurance
Conducts Complained OfDisagreement regarding Medical evidence submitted ,Complaint handling (Consumer Protection Code) , Delayed or inadequate communication, Rejection of claim
Decision Ref:
2022-0095
Sector:
Insurance
Product / Service:
Private Health Insurance
Conduct(s) complained of:
Disagreement regarding Medical evidence
submitted
Delayed or inadequate communication
Complaint handling (Consumer Protection Code)
Rejection of claim
Outcome:
Rejected
LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN
The late Policyholder incepted a health insurance policy with the Provider on 10 October
2017. The policy period in which this complaint falls, is from October 2019 to October
2020, during which period, sadly, the late Policyholder died.
The Complainant is the Estate of the late Policyholder. This complaint concerns the
Provider’s refusal to approve the late Policyholder’s January 2020 application for cover for
a high-cost cancer drug.
The Complainant’s Case
In his letter to this Office dated 22 June 2020, the Complainant set out the complaint, as
follows:
“On the 17th January 2020, [the Provider] refused our request to pre-authorise cover
for prescribed medications to treat my wife’s reoccurrence of cancer. My wife…has
successfully battled cancer on a number of occasions and we have been customers
of [the Provider] for many years.
To put matters into perspective, in mid-2018 we found out that my wife’s
oesophageal cancer had returned and surgery was required to remove her [surgery
details redacted]. This operation was successful and after a period recuperating in
- 2 -
/Cont’d…
hospital [my wife] made a good recovery. All of the health costs incurred at that
time were paid by [the Provider] under the terms of our health insurance policy…
In [date redacted], my wife’s consultant advised us of another reoccurrence of
cancer and in order to give [my wife] the ‘best chance’ the paramount treatment
option was for her to receive Pembrolizumab (immunotherapy drug) and Chemo-
therapy medications together as a ‘first-line’ treatment of cancer.
In December 2019, our consultant…submitted a pre-approval request for this blend
of medication to [the Provider] this pre authorisation was refused by [the
Provider] on 17 January 2020.
We immediately replied to [the Provider] and requested an urgent review and an
appeal. This request seemed to be getting passed around from one department to
another and we had difficulty initiating an appeal. We certainly felt [the Provider]
were ‘kicking the can down the road’ and perhaps would have preferred us to ‘just
go away’. One of the options/choices given to us at the time was whether we
wanted the matter treated as a complaint or an appeal? We found these
ultimatums very distressing …
Once we managed to action an appeal, we were requested to supply additional
medical details from our consultant we authorised the release of information from
our medical team.
On 13th February 2020, [the Provider] determined our appeal and reconfirmed [its]
refusal of cover as ‘the original decision stands’ – without ever receiving the
requested additional medical information from our consultant.
We expected any appeal to be determined/reviewed by a higher tribunal with new
eyes and believed that it could be approved in line with the approval process for a
‘reasonably favourable prognosis’ as described in our policy handbook – but the
common understanding of an appeal process was not afforded to us by [the
Provider] and [its] ‘appeal decision’ seems to have been made by the very same
team who had refused us in the first instance. This is completely imbalanced and
flies in the face of fairness from our position, the [Provider] appeal process
equates to something along the lines of a kangaroo court!
We feel the way we have been treated by [the Provider] is scandalous and it has
resulted in us having to pay in the region of €22,000 for access to the drugs our
consultant prescribed This intervention was ultimately proven successful and
eliminated the presence of tumours on [my wife’s] medical scans in April 2020.
Please be aware that the prescribed Pembrolizumab (aka Pembro/Keyrtuda)
medication is covered by other Health Insurance providers in Ireland for the same
condition specifically [a named health insurance provider] who have broken from
their peer group and now cover their policyholders for the same condition (unlike
[the Provider]).

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