Not upheld: Travel / life insurance claim disputes complaint against National Deposit Friendly Society Limited

Decision detail

Summary

Mr and Mrs H complained that National Deposit unfairly declined their private medical insurance claim for mechanical thrombectomy surgery for Mrs H's deep vein thrombosis. National Deposit initially authorised the procedure but later classified it as experimental and declined cover. The ombudsman found the claim was declined fairly because the procedure was not approved by NICE and not regularly carried out across the NHS, meeting the policy's experimental treatment exclusion. While National Deposit erred in giving initial authorisation without full information, this did not make the ultimate decline unfair. The ombudsman upheld the £2,000 compensation offer as fair and reasonable for the distress and inconvenience caused.

The Ombudsman's reasoning

The ombudsman found that the procedure (mechanical thrombectomy) met the policy's definition of experimental treatment as it was not approved by NICE, not recognised or regularly carried out across the NHS, and only available in selected NHS trusts with special arrangements. While National Deposit erred in giving initial authorisation without full information and should have waited for complete details from the consultant, this error did not make the ultimate claim decline unfair. The £2,000 compensation appropriately reflected the significant emotional and financial impact on Mrs H, including being informed of the declined cover on the day of surgery.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website