Not upheld: Motor insurance, claim handling complaint against National Deposit Friendly Society Limited

Decision detail

Summary

Mrs M purchased a private medical insurance policy in 2020 and was diagnosed with cancer in November 2020. She sought coverage for a planned bone marrow transplant in early 2021, but National Friendly declined the claim citing an exclusion in the policy terms. The estate complained that the exclusion was not prominent, expectations were raised over several months, and that earlier confirmation of the exclusion could have allowed earlier private treatment that might have saved her life. The ombudsman did not uphold the complaint, finding the exclusion was clearly stated in the policy terms and that the delay in confirming it did not materially affect Mrs M's treatment, as her NHS care would have continued regardless.

The Ombudsman's reasoning

The ombudsman found that the bone marrow treatment exclusion was clearly stated in the policy terms and conditions on the same page as the cancer cover section. While National Friendly could have confirmed the exclusion earlier when Mrs M first mentioned the bone marrow transplant in December 2020, this delay did not cause material difference to Mrs M's treatment as her NHS treatment would have continued regardless. The ombudsman noted that insurers can decide what level of risk to cover and exclude treatments, and that extensive cancer cover does not necessarily mean every type of treatment is covered. The £3,000 goodwill payment adequately compensated for the error in responding to the complaint and the delay in confirming the exclusion.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website