Not upheld: Other regulated complaint complaint against USAY BUSINESS LTD

Decision detail

Summary

Mr J complained that Usay mis-sold him a private medical insurance policy by switching him from Insurer A to Insurer B in November 2024. Mr J was concerned that his daughter's ongoing treatment would continue to be covered under the new policy. After the switch, Insurer B declined a claim for his daughter's treatment, citing pre-existing condition exclusions, despite Insurer A having covered the same treatment under identical moratorium terms. The ombudsman found that Usay provided suitable advice based on the information available at the time, recommending comparable cover at a lower premium with the same underwriting terms. The subsequent claim decline by Insurer B, despite identical policy terms to Insurer A, was not foreseeable by Usay and did not constitute mis-selling. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that Usay provided advice on an advised basis and recommended a policy suitable for Mr J's needs. The policy offered comparable cover under identical underwriting terms at a lower premium. Although Insurer B subsequently declined the claim for Mr J's daughter's treatment, this was not due to an error by Usay. The ombudsman noted that both insurers had identical moratorium terms, making it unclear why Insurer A had covered the treatment while Insurer B declined it. This inconsistency was not something Usay could reasonably have foreseen or accounted for when providing advice.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website