Not upheld: Travel / life insurance claim disputes complaint against Cigna Europe Insurance Company SA

Decision detail

Summary

Miss P claimed for lymphaticovenular anastomosis treatment for lymphoedema under her private medical insurance policy with Cigna. Cigna refused the claim on the basis that the procedure was experimental and not covered. The ombudsman examined the policy's requirement for 'evidence based treatment' and found that NICE does not recognise the procedure, the NHS considers it experimental, and Cigna's medical advisers reasonably concluded there was insufficient evidence of long-term effectiveness. Although the consultant provided peer-reviewed articles and noted the procedure is standard in Japan and used in Italy and Spain, the ombudsman upheld Cigna's decision as reasonable given the lack of long-term data and small patient numbers.

The Ombudsman's reasoning

The policy explicitly requires treatment to be 'evidence based' and recognised by NICE, Cigna's Medical Advisory Panel, or another recognised source. NICE does not recognise the procedure, the NHS considers it experimental, and Cigna's medical advisers concluded there was insufficient evidence of long-term effectiveness despite some supporting data. The fact that one previous claim was accepted outside policy terms does not establish the procedure as evidence-based for policy purposes.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website