Making a complaint about private medical insurance.

Last updated: 28th January 2021
 

On this page

  1. What is private medical insurance?
  2. Types of complaint we see
  3. What we look at
  4. How to complain
  5. Putting things right
  6. Case studies
  7. Resources

This page contains information about our general approach to complaints about private medical insurance. If you’re looking for information specifically in relation to Covid-19, please look at our dedicated page that contains information for consumers about complaints in relation to Covid-19.

What is private medical insurance?

Private medical insurance covers the cost of investigating and treating medical conditions. Some policies just cover private dental treatment. Some of the main policies available include:

  • individual policies – you pay an annual or monthly premium to get private medical treatment
  • group policies – you can opt in to a private medical policy offered by your employer
  • cash plans – you pay a monthly premium to receive a lump sum in certain situations, like if you’re admitted to hospital for more than 24 hours
  • dental policies – you pay a premium to get private dental treatment or get a contribution to the cost of your NHS treatment
  • “6-week plans” – if you have to wait more than 6 weeks to get treatment on the NHS, your policy will cover you for private treatment
  • international private medical insurance policies – you pay a premium to cover you for private medical treatment if you live in a country that’s not where you were born

Types of complaint we see

Claims

Customers may complain to us about the way their claim has been handled. This could be because their insurer:

  • is taking too long to pay their claim
  • hasn’t paid for all their treatment
  • has stopped paying for their treatment

Mis-sale

Customers may complain they’re unhappy with the sale or administration of their private medical insurance policy. This could be because they:

  • didn’t know they wouldn’t be covered for a particular medical condition
  • were told their policy would cover them for everything they needed

What we look at

Claims

We always look at the policy terms and conditions and industry guidance like the Insurance Conduct of Business Sourcebook (ICOBS). ICOBS places a responsibility on your insurer to handle claims promptly and fairly. And they shouldn’t reject a claim unreasonably.

Mis-sale

If the complaint is about a mis-sale, we’ll look at who sold the policy. We’ll also look at whether or not you were given advice when you bought the policy.

If the business provides advice, they have a responsibility to make sure the policy is right for you. If you bought the policy without advice, then you should have been given enough information to decide if the policy was right for you.

How to complain

If you have a complaint about private medical insurance, talk to your insurer first. They need to have the chance to put things right. They have to give you their final response within 8 weeks for most types of complaint.

If you’re unhappy with their response, or if they don’t respond, let us know. We’ll check your complaint is something we can deal with and, if it is, we’ll investigate to understand what happened and what went wrong.

Find out more about how to complain.

Putting things right

  • Your insurer is entitled to investigate your claim – and that might include getting information from medical professionals, which can take time. But we’d expect to see your insurer asking for, and chasing the information they need.

    If your insurer delayed the authorisation for your treatment, we appreciate that your health may have deteriorated during this time, or that you could have been in a lot of pain. So we might suggest compensation for your distress and inconvenience if we think the delay was unnecessary. The amount of compensation we’d recommend would depend on how the delay affected you.

    If your insurer has rejected a claim and we think it shouldn’t have done so – we’ll consider what impact this had on you.

    If you had treatment on the NHS, we might make an award for inconvenience to reflect that you didn’t have treatment at the time, place and with the consultant of your choice. If you did have treatment under the NHS because of your insurer’s delay in dealing with the claim, then we might also consider an award for loss of comfort.

  • If we find your policy was mis-sold, we may ask your insurer to:

    • cancel the policy from the beginning and refund your premiums
    • add simple interest at 8% a year from when each premium was paid, until the settlement is paid

    If the sale was made by an independent financial advisor (IFA) or an insurance broker, we may ask them to pay compensation.

Case studies

Insurer refused claim because of pre-existing condition

Bodhi took out a private health policy in late 2017. He contacted us because he’d made a claim for treatment of a lung condition in early 2018 that his insurer had declined. His insurer said his policy didn’t cover him for pre-existing medical conditions.

Insurance Medical Conditions

Read more 

Insurer wouldn’t pay for treatment at eye appointment because it was not pre-authorised

Erin had an appointment with a consultant. She had pre-authorisation for the appointment but she’d been told she’d need further authorisation if she wanted to claim for treatment. She later made a claim on her private health insurance policy for an eye injection during the appointment.

Insurance Private Medical Insurance

Read more 

Resources

When handling complaints about private medical insurance, we use the following resources: