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

Decision detail

Summary

Mr O claimed for a £135 ultrasound scan performed by a consultant radiologist at a private GP surgery. Health Shield refused the claim, requesting evidence that the scan was referred for as part of a specialist consultation, as required by the policy terms for non-hospital scans. The ombudsman upheld Health Shield's refusal, reasoning that radiologists typically review scan results rather than assess symptoms and determine the need for scans, meaning Mr O's consultation with Dr D likely occurred after the scan rather than before it. The ombudsman found no evidence supporting that the ultrasound was referred for as part of the consultation and therefore the claim was properly declined.

The Ombudsman's reasoning

The ombudsman determined that a radiologist's role is to examine and interpret scans rather than assess symptoms and determine the need for investigations. Therefore, Dr D's consultation was likely to review scan results rather than to refer for the scan itself. Since the ultrasound was not performed in a hospital, it could only be covered if referred for as part of a specialist consultation. As Mr O provided no evidence of such a referral, Health Shield's refusal was reasonable.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website