Not upheld: claim declined - pre-existing condition exclusion and moratorium period application complaint against HDI Global Specialty SE

Decision detail

Summary

Mr D claimed on his employer's private medical insurance policy for hip treatment in February 2024, but HDI Global Specialty SE declined the claim as a pre-existing condition falling within the policy's moratorium period (which began January 2022). Mr D complained that his treating consultant's clarification demonstrated the claim should be covered, distinguishing between earlier mechanical symptoms and later arthritic symptoms. The ombudsman found HDI acted fairly in declining the claim, as Mr D had experienced hip pain symptoms for almost 20 years within the relevant exclusion timeframes, and the medical evidence did not establish that the more recent symptoms were unrelated to the pre-existing condition. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman concluded that HDI reasonably applied the pre-existing condition exclusion because Mr D had experienced symptoms within the relevant timeframes. The ombudsman found HDI's reliance on the initial GP referral letter as an accurate summary of symptoms was reasonable, and placed less weight on clarifications provided after the claim was declined. The ombudsman accepted HDI's reasoning that the more recent arthritic symptoms were not distinguishable from or unrelated to the long-standing hip pain, particularly given the absence of any injury or trauma and the degenerative nature of arthritis. The ombudsman found HDI provided sufficient evidence to support their decision without requiring a specialist report to counteract the treating consultant's opinion.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website