Not upheld: Travel / life insurance claim disputes complaint against National Deposit Friendly Society Limited

Decision detail

Summary

Mr I held a private medical insurance 'Care Plus' plan with NDFS Limited and claimed for a dental veneer. NDFS Limited rejected the claim as it was cosmetic dental treatment and not listed on the scale of allowances. Mr I argued this was unfair, particularly as veneers were cheaper and less invasive than the alternative crown, and provided his dentist's letter supporting this. The ombudsman did not uphold the complaint, finding the policy terms clearly excluded cosmetic treatments and veneers were not listed on the scale of allowances, so NDFS Limited fairly declined the claim.

The Ombudsman's reasoning

The ombudsman found that veneers were not specifically referenced on the scale of allowances and therefore treatment not mentioned would not be covered under the policy terms. NDFS Limited is entitled to make commercial decisions about what treatment to cover, and the policy limitations were clearly set out in both the medical benefit section and general exclusions. The ombudsman considered the dentist's letter but concluded this did not require NDFS Limited to cover the procedure as it was not a listed treatment.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website