We look at Phil's complaint about his insurers decision to decline his claim.

What happened

Phil went to see his private GP because he had symptoms of breathlessness. The GP contacted a consultant at a local private hospital. There was a short discussion about Phil’s symptoms over the phone. Phil then drove to the hospital where he was seen as an outpatient before being admitted for several days.  

The insurer declined the claim on the basis the admission was an emergency and followed an unscheduled outpatient appointment.

How we helped

We asked to see the GP’s notes from the consultation, invoices from the hospital and the report from the consultant when Phil was discharged so that we could see what treatment Phil had received.

The diagnosis was that Phil had a severe chest infection which was linked to a pre-existing lung condition. We also listened to the phone calls between Phil and the insurer on the day he was admitted to hospital. These calls confirmed that Phil had originally asked for authorisation for an out-patient appointment.

Our decision

We didn’t think the admission was an emergency. Phil hadn’t gone to A&E; he’d driven to a hospital which didn’t have an emergency facility. He’d also phoned for pre-authorisation for an outpatient appointment so that he could have further tests. We also asked the insurer to comment on the medical evidence Phil had provided.

However, we explained to Phil that it wasn’t unreasonable for the insurer to reject the claim because there was a separate exclusion in his policy which meant he couldn’t claim for treatment linked to pre-existing medical conditions.