Private Health Insurance Decision Reference 2022-0282

• Case Outcome: Rejected
• Reference: 2022-0282
• Date: 23 August 2022
• Year: 2022
• Subject Matter: Private Health Insurance
• Finantial Sector: Insurance
• Conducts Complained Of: Rejection of claim - late notification,Failure to process instructions, Poor wording/ambiguity of policy

Decision Ref:

2022-0282

Sector:

Insurance

Product / Service:

Private Health Insurance

Conduct(s) complained of:

Rejection of claim - late notification

Failure to process instructions

Poor wording/ambiguity of policy

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

This complaint arises from the Provider declining the Complainant’s claim under his health

insurance policy due to limitation periods for medical expenses.

The Complainant’s Case

The Complainant incepted his health insurance policy with the Provider on 1 December

2018. His policy period runs from 1 December to 30 November of the following year.

In early December 2020 the Complainant logged onto the Provider's online portal to submit

his claims for 2019 (December 2018 – November 2019) and 2020 (December 2019 –

November 20202). He submitted his claims for 2020 but found that the system did not allow

him to do so for the 2019. And he received the online message:

“The claims must be submitted within six months of the end of the year policy.”

The Complainant subsequently received an email dated 4 December 2020 headed “Your

claim has been paid”. When the Complainant logged in to check what payment had issued,

he discovered that a claim to the value of €50 (fifty euro) for 2020 had been rejected. The

Complainant noted that this rejection was not mentioned in the email correspondence and

he states that: