Types of complaint we see
Customers who’ve made a claim on their private medical insurance (PMI) sometimes come to us with a complaint that their:
- claim has been declined
- insurer hasn’t paid out as much as they were expecting
Examples of common claims issues we see
A PEMC is a physical or mental health condition the customer had before they took out the policy. Claims are usually declined because the customer had symptoms of, or was receiving treatment for, the condition before they took out the policy.
When we’re looking at whether it’s fair for you to decline the claim we’ll usually consider:
- when the policy was taken out – and any medical questions asked
- when the customer started experiencing symptoms
- dates of any medical appointments
- the policy terms and conditions, and whether there’s a moratorium clause
- copies of medical records
PEMCs and misrepresentation
In cases where the customer complains that you’ve turned down their claim because of non-disclosure or mis-representation, we’ll try to establish if the customer:
- provided accurate information
- took reasonable care
We’ll do this by looking at:
- details of the questions and answers from the medical screening and sale of the policy
- the customer’s relevant medical records
- the underwriting criteria (if you say you wouldn’t have covered the customer if they’d declared the condition or symptoms)
You can find out more about how we handle complaints about pre-existing medical conditions on our website.
PMI policies usually cover acute conditions, but not chronic conditions.
If you decline a claim on the basis the customer has a chronic condition, you need to show the condition is chronic rather than acute.
Acute conditions can become chronic. If this happens and you decide to withdraw cover, we’d expect you to tell your customer quickly and with empathy. We’d also expect you to be able to justify your decision to do this through medical evidence or opinion.
Most PMI policies will not pay for treatment or procedures which are experimental or unproven based on established medical practice. This may be because the drugs aren’t licenced or because the particular procedure isn’t approved by the National Institute for Health and Care Excellence (NICE).
We’ll consider the policy terms and conditions taking into account that:
- this is a constantly evolving area as drugs or treatments which are ‘experimental’ might become standard practice over time
- medication is often prescribed by medical practitioners for use outside the terms of the licence when it’s considered medically appropriate
- some insurers may cover experimental treatments as a gesture of goodwill
We’ll weigh up all the evidence and decide whether you’ve acted fairly.
Most policies won’t cover emergency treatment, admission to hospital in an emergency or urgent admission following an unplanned outpatient appointment.
When deciding whether treatment was urgent or an emergency, we’ll take into account the overall circumstances, including any medical evidence available.
We’ll look at whether the customer:
- went to hospital on the advice of a medical professional
- travelled to hospital by NHS or private ambulance
- contacted you (and what they said)
- was admitted to hospital
- had treatment
- was given a diagnosis
Most PMI policies don’t cover medical expenses for routine procedures during pregnancy or childbirth.
Some policies will cover the treatment of an acute condition which may happen during pregnancy like:
- ectopic pregnancy
- post-partum haemorrhage
- retained placental membrane
We often see complaints about insurers refusing to cover caesarean sections, even if the customer has been advised to have a caesarean by their doctor or consultant.
Some insurers agree to cover caesarean sections in limited circumstances – for example, where there is clear medical evidence that there is a specific risk to the mother’s life.
Other insurers may not agree to cover the cost of a planned caesarean section, but may agree to cover the cost of an emergency caesarean if the need arises during the course of a natural birth.
We’ll also consider the information or advice the customer was given about their policy at the point of sale. If the terms weren’t made clear to the customer and there could be a valid mis-sale complaint.
Preventative treatment may include surgery, tests or investigations. The customer will usually be in good health but concerned about the risk of illness. We don’t usually consider it unreasonable for you to apply this exclusion to a policy, as long as it’s applied reasonably.
Occasionally, treatment of an acute condition can also be preventative. In these cases we’ll need to weigh up the medical evidence to decide what’s fair.
Private medical insurance policies usually exclude cosmetic treatment like nose or breast reconstruction. But if evidence suggests the treatment is required on medical grounds to cure or relieve the symptoms of a medical condition, we may tell you to meet the claim.
Read our case study about how we helped with a complaint about cosmetic treatment – ‘My insurer wouldn’t pay for my breast reduction surgery because they said it was a cosmetic treatment’.
A customer may sometimes complain that you haven’t assessed their claim quickly enough. In these cases, we’ll establish a timeline including key dates including when a claim was submitted and dates when you asked for information.
We appreciate that you’ll often need to ask for information from third parties like hospitals and the customer’s GP. It’s not your fault if you need to wait for information, but we would expect you to chase the information at regular intervals.
Here’s an example of a case we helped – ‘It took my insurer four months to settle my medical insurance claim’.
Sometimes a customer is unhappy because they can’t use their choice of consultant, or go to the hospital they want to use.
Private medical insurers usually have a list of ‘recognised’ consultants and hospitals whose fees your prepared to meet up to the policy benefit limits. For hospitals, this usually means you've entered into a contract with the hospital to agree on the level of charges you’ll have to pay.
In some cases, we might ask you to meet the full fees of the specialist or hospital even if the fees are higher than you’d normally pay.
We’d look at all the circumstances to decide what’s fair and reasonable including:
- how far the customer would need to travel to see a recognised consultant or to attend a hospital on your list
- the customer’s state of health
- how regularly the customer will need to attend the hospital or receive treatment
Generally, we think an insurer has the right to decide who they ‘recognise’ to treat their policyholders.
Some private medical insurance policies include dental or oral treatment as an additional benefit. But the following treatments aren’t usually covered:
- routine treatment and fillings
- dental inspections and dental hygiene
- dentures, crowns and bridges
- cosmetic dentistry
- jaw shrinkage
- gum disease
If a customer has a stand-alone dental plan or a ‘cash plan’, they might be entitled to claim the cost of some treatment up to the maximum policy benefit.
Handling a complaint like this
As with any complaint, we’ll expect you to work with your customer to get to the bottom of what happened, investigate fairly whether anything went wrong, and – where appropriate – take steps to put things right.
If you don’t reply within the time limits for responding to a complaint, or the customer disagrees with your response, they can bring their complaint to us. We’ll check it’s something we can deal with, and if it is, we’ll investigate.
We’ll expect you to be able to show us that you’ve investigated the complaint thoroughly, and have reflected carefully on the circumstances.
Find out more about how to resolve a complaint.
Information we will ask for when we receive a complaint
Once a complaint has been referred to us, we will ask you to provide information about your side of events.
The typical information we would normally expect to see about this type of complaint for includes:
- policy terms and conditions – from the correct time (the date of the event leading to the complaint)
- policy schedule
- policy renewal documentation if appropriate
- all medical evidence/reports relied upon
- claim notes and correspondence – including all call recordings
- a timeline of events
- a breakdown of any claims settlement offered
- underwriting criteria as applicable
We may ask for further information or documents, depending on the circumstances of the case.
Read more about how we handle complaints.
What we look at
We need to see the policy terms and conditions, and the schedule of insurance in every PMI case so we can understand how the policy works and what exclusions apply.
We’ll always use the relevant rules and industry guidance when deciding what’s fair and reasonable. The rules place a responsibility on you to handle claims promptly and fairly.
Putting things right
If we think you have made a mistake or treated a consumer unfairly, we'll ask you to put things right. Our general approach is that the customer should be put back in the position they would have been in if the problem hadn't happened.
The exact details of how we'll ask you to put things right will depend on the complaint, and how the customer lost out. In some cases, we may also ask you to compensate the customer for any distress or inconvenience they've experienced as a result of the problem.
‘My insurer turned down my claim for an acute flare-up of my chronic condition’
Insurance Private Medical Insurance
‘My insurer won’t pay for experimental treatment, even though my consultant wanted to use the treatment’
‘My insurer turned down my claim for a caesarean section, even though it was essential’
Insurance Distress and inconvenience Up to £5,000 Medical Conditions
‘My insurer won’t pay for my preventative treatment’
Insurance Private Medical Insurance Medical Conditions
Business Support Hub
If you want to talk informally about a complaint you've received, you can speak to our Business Support Hub. They can give general information on how the Financial Ombudsman might look at a particular complaint. We also offer guidance on our rules and how we work.
Find out how to contact the Business Support Hub.