Private Health Insurance Decision Reference 2022-0323

• Case Outcome: Rejected
• Subject Matter: Private Health Insurance
• Reference: 2022-0323
• Date: 26 September 2022
• Finantial Sector: Insurance
• Conducts Complained Of: Rejection of claim - depression/mental health illness,Failure to process instructions, Rejection of claim

Decision Ref:

2022-0323

Sector:

Insurance

Product / Service:

Private Health Insurance

Conduct(s) complained of:

Rejection of claim - depression/mental health

illness

Failure to process instructions

Rejection of claim

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

The First Complainant held a Health Insurance Policy with the Provider. The Second

Complainant, his daughter, is a named person on the Policy. This complaint concerns the

Provider’s refusal to provide cover for the Second Complainant’s treatment for her condition

in a specific treatment facility. The Policy term in which this complaint falls, is from 1

February 2020 to 31 January 2021.

The Complainants’ Case

The First Complainant says that the Second Complainant was diagnosed with anorexia

nervosa and that following consultation, the family GP recommended that the Second

Complainant be admitted into Hospital A for treatment of her condition.

The First Complainant says that the Provider declined to cover any treatment that the

Second Complainant may undergo in Hospital A, as it advised that there is no cover under

his Policy in respect of this treatment facility.

The First Complainant sets out the Complainants’ complaint in the Complaint Form he

completed in November 2020, as follows:

“My daughter [the Second Complainant] is battling Anorexia. We found this out

about 2 months ago. We were referred to numerous different treatment centres by

our GP … After meeting with [the Second Complainant], [our GP] advised us that the

best course of action was to refer [the Second Complainant] to [Hospital A], and

[Hospital A] agreed to help [her].