Private Health Insurance Decision Reference 2023-0173

• Case Outcome: Upheld
• Subject Matter: Private Health Insurance
• Reference: 2023-0173
• Date: 22 August 2023
• Finantial Sector: Insurance
• Conducts Complained Of: Claim handling delays or issues,Dissatisfaction with customer service

Decision Ref:

2023-0173

Sector:

Insurance

Product / Service:

Private Health Insurance

Conduct(s) complained of:

Claim handling delays or issues

Dissatisfaction with customer service

Outcome:

Upheld

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

The complaint arises out of a health insurance policy held with the Provider, covering both

Complainants, a husband and wife.

The Complainants submit that during a telephone conversation on 30 December 2019

between the first Complainant and the Provider, she was first informed that all outpatient

expense claims had to be submitted within 12 months of the expense being incurred, and

that any expense claimed outside of this 12-month timeframe, would no longer be

admissible to claim for benefit payments.

The First Complainant says that during the same telephone call, she was further advised that

this was already an existing rule governing policyholders’ claims for expenses, but that the

rule was now being strictly enforced by the Provider, and all policyholders had been

informed of this change when their policies were renewed in 2018 and onwards.

The Complainants submit that during the period 2008 – 2017, they incurred outpatient

expenses which they are seeking to claim back from the Provider.

Further the Complainants submit that they incurred optical and dental expenses in 2018

which they claimed for in March 2019, one month outside of the 12-month claim period,

which they also want reimbursed.