Not upheld: Other regulated complaint complaint against Medicash Health Benefits Limited

Decision detail

Summary

Mrs A complained about Medicash's denial of a £160 CT scan claim for her son, arguing it should have been assessed under the specialist consultations and scans section rather than routine dental treatment. Medicash had denied the claim because the son had exceeded his allowance under the routine dental treatment section for the benefit year. The ombudsman found that while a CT scan is specialist in nature, it falls within the routine dental treatment section under the policy wording, and the alternative section explicitly excludes dental treatments. Therefore, Medicash correctly assessed the claim under routine dental treatment, and the denial was appropriate given the exhausted benefit allowance.

The Ombudsman's reasoning

The ombudsman found that although a CT scan is a specialist x-ray machine and would not usually be considered routine, it is nonetheless covered under the routine dental treatment section (10.1) because the policy wording covers dental x-rays without restricting the type of treatment. The claim could not be assessed under section 10.4 (specialist consultations, diagnostic tests and scans) because that section explicitly excludes routine dental treatments and the scan was not arranged by a GP or Specialist Consultant. Therefore, Medicash correctly assessed the claim under section 10.1, and the denial was appropriate because the son had exhausted his benefit allowance for that section.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website