How we can help if you have a complaint about private medical insurance (including dental insurance).
What is private medical insurance?
Private medical insurance covers the cost of investigating and treating medical or dental conditions. Some of the main policies available include:
- individual policies – you pay an annual or monthly premium to get private medical treatment
- group policies – you join a private medical policy offered by your employer
- cash plans – you pay a monthly premium to get a lump sum in certain situations - for example, if you’re admitted to hospital for more than 24 hours
- dental policies – you pay a premium to get private dental treatment or a contribution to the cost of your NHS treatment
- 6-week plans – you may be covered for private medical treatment if you have to wait more than 6 weeks for treatment on the NHS
- international private medical insurance policies – you’re covered for private medical treatment if you live in a country that’s not where you were born
Types of complaint we see
People typically contact us to complain about the way their claim has been handled or because they’re unhappy with the sale of the administration of their policy. We hear from people who tell us that:
- their insurer is taking too long to pay their claim
- their insurer hasn’t paid for all their treatment
- their insurer has stopped paying for their treatment
Or that they:
- didn’t know they wouldn’t be covered for a pre-existing medical condition
- were told their policy would cover them for everything they needed
Important information about group policies
If you’ve taken out private medical cover through your employer, you aren’t the policyholder - you’re a beneficiary of the cover. You can still complain to us about a claim under a group policy.
However, if you have a complaint about the sale of a group policy, you’ll need to ask your employer to complain to us. This is because the insurer first sold cover to your employer – not directly to you. Your employer then offered you the policy it bought. There are rare exceptions to this rule where you, as the policy beneficiary, bought the policy on behalf of your employer.
We can’t get involved in employer-employee disputes about cover.
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, if anything, went wrong.
Find out more about how to complain.
What we look at
To help us consider a complaint fairly, we’ll ask you to provide some information. We’ll make our decision about what happened using evidence provided by you, the financial business and any relevant third parties. In reaching a decision, we consider:
- the relevant law
- any regulations that applied at the time
- any industry codes of conduct in force at the time
- the terms and conditions of the policy
We always look at the policy terms and conditions when we investigate complaints about claims. Your insurer has to handle claims promptly and fairly. They shouldn’t reject a claim unreasonably.
If your complaint is about a mis-sold policy, 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, you should have been given enough information to decide if the policy was right for you.
Putting things right
If we decide you’ve been treated unfairly, or that the financial business has made a mistake, we’ll ask them to put things right. Our general approach is that you should be put back in the position you would have been in if the problem hadn’t happened. We may also ask the financial business to compensate you for any distress or inconvenience you’ve experienced as a result of the problem.
The exact details of how we’ll ask the business to put things right will depend on the nature of the complaint, and how you lost out.
The following examples give an idea of our approach:
Your insurer is entitled to investigate your claim. This might include getting information from medical professionals, which can take time. But we’d expect to see your insurer asking for, and chasing if necessary, 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, we’ll consider what impact this has had on you.
If you had treatment on the NHS, we might make an award for inconvenience and loss of comfort. This is to reflect that you didn’t have treatment at the time, place and with the consultant of your choice.
If we find your policy was mis-sold, we may ask your insurer to:
- cancel the policy and refund your premiums from the beginning
- 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.
Read more about how we award compensation.
Insurer refused claim because of pre-existing condition
Insurance Medical Conditions
Insurer wouldn’t pay for treatment at eye appointment because it was not pre-authorised
Private Medical Insurance Insurance
‘My insurer wouldn’t pay for my breast reduction surgery because they said it was a cosmetic treatment’
Private Medical Insurance
When handling complaints about private medical insurance, we use the following resources:
Information for financial businesses
If you’re a business looking for information to help you resolve complaints or want to find out more technical information, you can find more detail about complaints about private medical insurance in the business section of our website.