Upheld: PPI mis-selling complaint against USAY BUSINESS LTD

Decision detail

Summary

Mrs W purchased a private medical insurance policy from Usay in December 2024 on an advised basis. When she made a claim in July 2025 for a gynaecologist referral, she discovered that specialist consultations and minor diagnostic tests were not covered and had to pay for these herself. Usay accepted the policy had been mis-sold, as the advisor failed to explain this significant limitation during the sale call, and initially offered a premium refund and £150 compensation. The ombudsman upheld the complaint and ordered Usay to reimburse Mrs W's consultation and scan costs (less excess) with 8% interest, plus £500 total compensation for distress and inconvenience, finding that had the policy not been mis-sold, Mrs W would have chosen alternative cover that included these benefits.

The Ombudsman's reasoning

The ombudsman found that Usay, having sold the policy on an advised basis, was required to ensure the policy was suitable and that Mrs W received sufficient information about how it worked. The call recording confirmed the advisor failed to explain that specialist consultations and minor tests were not covered, despite having the opportunity to do so. This was a significant omission given that such cover is ordinarily expected in private medical insurance policies. Had the policy not been mis-sold, Mrs W would likely have chosen a policy that included these benefits, meaning her consultation and scan costs would have been covered. The ombudsman rejected a premium refund as inappropriate since the costs should be reimbursed directly. The £500 compensation was considered fair given the impact on Mrs W, including the difficulty of obtaining new cover with the condition now treated as pre-existing.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website