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

Private Medical Insurance Insurance

Erin complained when her insurer refused to pay for treatment at her eye appointment.

What happened

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. Her insurer declined the claim because they said she’d not had pre-authorisation and the condition was chronic.

Erin thought this was unfair and complained to her insurer. Unhappy with the outcome, she contacted us to make a complaint.

What we said

We asked to listen to the call recordings. Erin was told during the call she needed to get authorisation before starting treatment. We looked at the terms and conditions of the policy. The terms defined a chronic condition as one that couldn’t be cured or needed ongoing monitoring or treatment. We checked a copy of the consultant’s notes from the appointment. He confirmed a diagnosis was made during the appointment and although there was no known cure for the condition, the injections would slow the symptoms Erin was experiencing.

We explained to Erin the insurer had acted fairly as they’d made it clear that she’d need pre-authorisation before getting any treatment. Erin’s consultant had also confirmed that the condition wasn’t curable. We empathised with Erin, but it was reasonable for the insurer to conclude she had a chronic condition on the basis of the medical evidence available.