Not upheld: claims handling error and policy excess liability complaint against Vitality Health Limited

Decision detail

Summary

Mr B complained about Vitality Health Limited's handling of claims under his group private medical insurance policy. In June 2023, Mr B underwent an MRI at hospital C but was transferred to another provider due to delays. Vitality wrongly told Mr B in August 2023 that he had nothing to pay, but later advised that he owed a £100 annual excess for the 2023-24 policy year. This resulted in payment chasers from hospital C months later. Mr B complained that Vitality failed to identify that C could not provide appropriate care in a reasonable timeframe and should have taken responsibility. Vitality agreed to settle the £100 excess directly with C and offered £50 compensation. The ombudsman found the complaint not upheld, determining that Vitality was not contractually responsible for the hospital's service delays and that its settlement offer was fair and reasonable.

The Ombudsman's reasoning

The ombudsman found that while Vitality wrongly told Mr B he had nothing to pay in August 2023, the policy terms clearly show Mr B was liable for the £100 excess as it was his first claim in the 2023-24 policy year. The ombudsman considered Vitality's agreement to settle the excess directly with C to be fair and pragmatic, effectively waiving the contractual excess and preventing further correspondence. The ombudsman rejected Mr B's claim that Vitality was responsible for hospital C's inability to provide timely care, as the policy terms explicitly limit Vitality's liability to paying for treatment and exclude liability for defects in quality or availability of services. The ombudsman found the £50 compensation, together with the £100 paid to C, to be fair and proportionate, and found insufficient medical evidence linking Mr B's anxiety condition to Vitality's mistake.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website