Not upheld: Travel / life insurance claim disputes complaint against Vitality Health Insurance Limited

Decision detail

Summary

Ms M took out private health insurance with Vitality in September 2018 on a moratorium basis excluding pre-existing conditions. In May 2019 she dislocated her left shoulder while putting up a curtain pole and underwent surgery, claiming approximately £6,400 for treatment. Vitality declined the claim, stating the shoulder injury was related to Ms M's pre-existing condition of hypermobility/unstable joints documented in her medical records within the five years before the policy started. Ms M argued the injury was caused by the specific accident and that she had not been formally diagnosed with hypermobility. The ombudsman found Vitality fairly declined the claim as the medical evidence, including the surgeon's letter, confirmed the injury was related to her pre-existing hypermobility condition, which fell within the moratorium exclusion period.

The Ombudsman's reasoning

The ombudsman found that Ms M's medical records clearly documented a pre-existing condition of hypermobility/unstable joints within the five years before the policy started. Although Ms M had not previously had treatment to her left shoulder specifically, the policy's definition of 'related conditions' includes any condition reasonably considered to be associated with another condition. The surgeon's letter itself stated the tear resulted from the dislocation, and medical opinion indicated that a curtain pole injury would be unlikely to cause such a dislocation in someone without joint health problems. Therefore, Vitality reasonably concluded the injury was related to the pre-existing hypermobility condition and fairly declined the claim under the moratorium terms.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website