Not upheld: claim declined - pre-existing condition exclusion under moratorium clause complaint against Vitality Health Limited

Decision detail

Summary

Ms F held a business healthcare plan with Vitality from May 2024 on moratorium terms and made a claim in July 2025 for sclerotherapy treatment related to varicose veins. Vitality declined the claim citing the moratorium clause, which excludes pre-existing conditions present or for which advice was sought in the five years before cover started. The ombudsman upheld Vitality's decision, finding that Ms F's varicose veins were documented in 2010 and she had sought medical advice about the condition in September 2023 (8 months before inception), placing it within the exclusion period. Since the claim was made only 14 months after inception, the condition had not met the two-year continuous period without treatment or advice required for eligibility. Vitality's £50 compensation for requesting unnecessary further information was accepted as fair.

The Ombudsman's reasoning

The ombudsman found that the policy terms clearly exclude pre-existing medical conditions for which an insured member had symptoms, sought advice, received treatment, or was aware existed in the five years before cover started. The varicose vein condition met this exclusion because: (1) it was documented in GP records from 2010, well within the five-year period; (2) Ms F sought medical advice about it in September 2023 when she asked the nurse to examine the rash on her leg, which the nurse documented as resembling varicose vein blood vessels; and (3) this consultation occurred only 8 months before the policy inception. Since the claim was made 14 months after inception, the condition had not met the two-year continuous period without treatment, advice or medication required for pre-existing conditions to become eligible. Therefore, Vitality's decision to decline the claim was reasonable and fair.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website