‘My insurer turned down my claim for an acute flare-up of my chronic condition’

Insurance Private Medical Insurance

Dylan raised a complaint when his private medical insurance claim was turned down. The insurer believed the claim arose due to him having a chronic condition.

What happened

Dylan had a chronic condition. When he had an accident and hit his head, he said he experienced an acute flare-up of his chronic condition symptoms. He made a claim for spinal surgery, but his insurer declined the claim. The reason it gave for turning it down was that he had a chronic condition, rather than an acute exacerbation of his existing health problem.

Dylan thought this was unfair and complained to his insurer. Unhappy with its response, he referred his complaint to us.

What we said

We looked at the medical evidence from Dylan’s GP and consultants he’d seen on the NHS and on a private basis. We took into account what Dylan told us about his symptoms before and after the accident. And we checked whether the surgery was likely to restore Dylan to his former state of health.

We could see that Dylan had been experiencing the same symptoms before he bumped his head. The consultant, who’d examined Dylan a number of times over a two year period, had made no recommendation for the surgery to be carried out. When we checked the medical reports all the consultants said that the surgery might stop Dylan’s symptoms – but he’d need ongoing treatment and monitoring.

We explained to Dylan that we didn’t think it was unreasonable for the insurer to decline the claim on the basis that the condition was chronic. We said that there wasn’t enough evidence to suggest there was an acute flare-up of the condition, or that the surgery would restore him to his former health.