Private Health Insurance Decision Reference 2022-0128

• Case Outcome: Rejected
• Reference: 2022-0128
• Date: 11 April 2022
• Year: 2022
• Subject Matter: Private Health Insurance
• Finantial Sector: Insurance
• Conducts Complained Of: Claim handling delays or issues,Dissatisfaction with customer service

Decision Ref:

2022-0128

Sector:

Insurance

Product / Service:

Private Health Insurance

Conduct(s) complained of:

Claim handling delays or issues

Dissatisfaction with customer service

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

This complaint concerns a private health insurance policy that the Complainant holds with

the Provider. The initial complaint was that the Provider had wrongfully declined the

Complainant’s claims and that it failed to deal with the complaint in a timely manner. During

this Office’s investigation, the Provider decided to accept the Complainant’s claim after new

information which was submitted “clarified” the matter. Following this, the Complainant’s

Representative states she wishes to have the matter progressed to adjudication as he

contends the Provider unnecessarily prolonged the process.

The Complainant’s Case

The Complainant is represented by his daughter in respect of the complaint (the

Complainant’s Representative).

The Complainant’s Representative submits that in June 2014 the Complainant had

contacted the Provider to discuss a cheaper plan option and that, as a result of this

discussion, the Complainant’s policy was downgraded on 1 July 2014 to a less expensive

policy that contained fewer benefits than the previous policy which he held with it.

The Complainant’s Representative submits that in June 2016 she discovered, through

discussions with the Complainant, that he had downgraded the health insurance policy in

2014. The Complainant’s Representative submits that upon hearing this information she

immediately contacted the Provider on the Complainant’s behalf and that as a result of this

discussion with the Provider, the Complainant’s policy was upgraded on 17 June 2016.