Not upheld: Service failures generally complaint against National Deposit Friendly Society Limited

Decision detail

Summary

Mr B and Mrs B complained about how National Friendly handled a claim for Mr B's shoulder injury under Mrs B's private medical insurance policy and the subsequent renewal terms. The original 10-year policy was extended to 28 February 2020, and National Friendly authorised a consultation and MRI in February 2020. When offering renewal, National Friendly excluded Mr B's shoulder injury as a pre-existing condition, which Mrs B rejected. The ombudsman did not uphold the complaint, finding that step-by-step treatment authorisation is standard practice and that the policy terms explicitly permitted exclusion of pre-existing conditions upon renewal.

The Ombudsman's reasoning

The ombudsman found that National Friendly acted fairly by authorising treatment on a step-by-step basis, which is standard practice for insurers who cannot know at the outset what treatment will be required. The ombudsman also found that insurers are entitled to decide the terms on which they offer cover, and the policy terms explicitly stated that pre-existing conditions may be subject to medical exclusions or premium increases upon renewal. National Friendly was therefore entitled to exclude Mr B's shoulder injury as a pre-existing condition in the renewal policy offer.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website