Not upheld: Home insurance claim disputes complaint against Health Shield Friendly Society Limited

Decision detail

Summary

Mrs S complained that Health Shield unfairly rejected claims for treatment her partner Mr B received between 17 July 2023 and 31 July 2023. Mrs S had submitted an application to add Mr B to her health cash plan on 17 July 2023, and when the 'pending' status was removed from the online account, she assumed he was covered. However, Health Shield's cover for Mr B did not commence until 1 August 2023, when Mrs S's contributions for his coverage began. The ombudsman found that the policy terms clearly required the policyholder to be contributing at the appropriate rate to make claims, and that Mrs S should have contacted Health Shield to confirm the cover start date rather than assuming coverage based on the removal of the pending status. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that whilst Mrs S's confusion was understandable, Health Shield had not acted unfairly in rejecting the claims. The policy terms clearly state that claims can only be made if the policyholder is contributing at the appropriate rate. Since Mrs S was not contributing for her partner's cover until August, the claims for July treatment were properly rejected. The removal of the 'pending' status did not constitute confirmation of cover commencement. The ombudsman considered it reasonable to expect Mrs S to have contacted Health Shield to confirm the cover start date rather than assuming coverage based on the removal of the pending status.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website