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

Insurance Private Medical Insurance

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. 

How we helped

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

Putting things right

We explained to Erin that 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.