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

Decision detail

Summary

Mr G claimed under his private medical insurance policy for his daughter Miss E's lymph node transfer operation to treat lymphedema. Vitality refused the claim citing both a chronic condition exclusion and an experimental treatment exclusion. The ombudsman found that while the condition was not chronic (as the operation aimed to be curative), the treatment was experimental because it was not yet established medical practice in the UK, being performed only in limited circumstances by a small number of consultants. The ombudsman upheld Vitality's refusal to pay the claim as the experimental treatment exclusion in the policy was correctly applied.

The Ombudsman's reasoning

The ombudsman found that while the condition itself was not chronic (as the operation was intended to be curative), the treatment was experimental because it was not yet established medical practice in the UK. The procedure was only being undertaken in limited circumstances in the NHS by a small number of consultants, and there was insufficient evidence of its proven effectiveness as standard treatment for Miss E's condition. The issuance of new CCSD codes did not establish the procedure as established medical practice. Therefore, Vitality correctly applied its policy exclusion for experimental treatments.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website