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

Decision detail

Summary

Mr S claimed under his private medical insurance policy with Health Shield for a health screening appointment, but the claim was declined because the screening took place at a hotel rather than in a hospital or clinic as required by the policy terms. Health Shield had correctly communicated this requirement to Mr S during a November 2021 phone call. Although an investigator initially upheld the complaint, the ombudsman disagreed, finding that the policy terms were clear and that Mr S had made the error in selecting the venue. The ombudsman determined that Health Shield had not made a mistake and therefore declined to uphold the complaint.

The Ombudsman's reasoning

The ombudsman found that Health Shield's policy terms were clear and unambiguous in requiring health screening to take place in a hospital or clinic setting. Health Shield provided Mr S with correct information during the phone call, and Mr S made the error by choosing a hotel venue. The ombudsman determined it would be unfair to require Health Shield to compensate Mr S for a mistake the firm did not make. The ombudsman noted that it is for Health Shield to decide how to conduct its business and the firm operated within the scope of the policy terms.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website