Private Health Insurance Decision Reference 2022-0095

• Case Outcome: Rejected
• Reference: 2022-0095
• Date: 15 March 2022
• Year: 2022
• Subject Matter: Private Health Insurance
• Finantial Sector: Insurance
• Conducts Complained Of: Disagreement 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]).