Upheld: Home insurance claim disputes complaint against Health Shield Friendly Society Limited

Decision detail

Summary

Mr E claimed £50 under his health cash plan policy for new glasses purchased for £47 by card with the remainder financed through credit. The receipt showed an insurance charge which was not covered by the policy. Health Shield initially paid £8 based on incorrect assumptions, then claimed the optician had confirmed the insurance was not included in the £47 payment. When the complaint was escalated, Health Shield acknowledged this was unclear from the call. The ombudsman upheld the complaint, finding Health Shield should have properly clarified the payment details with the optician initially and correctly advised Mr E to obtain an optician's letter, which would have enabled earlier payment of the claim. The ombudsman ordered £50 compensation for the inconvenience and delay caused.

The Ombudsman's reasoning

The ombudsman found that while it was reasonable for Health Shield to seek clarification about the payment composition given the ambiguous receipt, Health Shield should have attempted to confirm the position with the optician during the initial call rather than making assumptions. When Health Shield subsequently claimed the optician had confirmed the payment didn't include insurance, this was inaccurate. The ombudsman concluded that if Mr E had been correctly advised he needed to obtain a letter from the optician initially, he would likely have done so regardless of pursuing the complaint, allowing Health Shield to pay the claim based on correct information at an earlier date.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website