Not upheld: Travel / life insurance claim disputes complaint against Health Shield Friendly Society Limited

Decision detail

Summary

Mr L and Mr T complained that Health Shield declined their 2019 health screening claims despite paying identical claims in 2018. Health Shield explained it had paid the 2018 claims in error, having misunderstood the nature of the service provided by company M. The ombudsman found that the service was only a blood test with a report, not a full health screening as defined in the policy, and therefore ineligible for cover in both years. Although sympathising with the claimants' position, the ombudsman concluded that Health Shield was entitled to decline the 2019 claims once it realised the service was ineligible, and that the claimants were not disadvantaged overall since the 2018 claims should never have been paid. The complaint was not upheld.

The Ombudsman's reasoning

The policy clearly defines a full health screening as involving medical history, physical examination, tests, laboratory tests, scans or X-rays, and potentially counselling or referral. The service provided by M in both 2018 and 2019 was only a blood test with a report, which does not meet this definition. Although Health Shield paid the 2018 claims in error, this does not obligate it to pay the 2019 claims. Once Health Shield realised the service was ineligible, it was reasonable to decline the 2019 claims. Mr L and Mr T were not disadvantaged overall because if Health Shield had correctly assessed the 2018 claims, it would not have paid them either, resulting in the same net outcome.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website