Not upheld: claim rejection and poor claims handling complaint against BUPA Insurance Limited

Decision detail

Summary

Mrs H complained about Bupa's rejection of her claim for a December 2024 eye consultation related to 2023 surgery. Bupa initially rejected the claim citing macular degeneration as a chronic condition, but later accepted Mrs H did not have this condition. The hospital confirmed the consultation was a routine six-monthly monitoring check-up following the 2023 surgery. The ombudsman found Bupa's rejection was reasonable under the policy's exclusion of routine follow-up consultations and monitoring, despite Bupa's poor handling in providing conflicting information. The ombudsman upheld Bupa's offer of £100 compensation and coverage of the consultation as fair redress for the service failures.

The Ombudsman's reasoning

The ombudsman applied FCA rules requiring insurers not to unreasonably reject claims. The policy explicitly excludes routine follow-up consultations and monitoring of medical conditions. Based on the hospital's confirmation that the December 2024 consultation was a routine six-monthly check-up for monitoring purposes, Bupa's rejection was reasonable. Although Bupa caused confusion by wrongly citing macular degeneration and incorrectly advising coverage, its offer of £100 compensation plus coverage of the consultation as a gesture of goodwill was proportionate to the service failure.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website