Not upheld: claim handling - fee schedule application and communication delays complaint against Aviva Insurance Limited

Decision detail

Summary

Mrs S complained to Aviva about its handling of her private medical insurance claim for ankle surgery performed by specialist Mr C. Aviva only paid a contribution towards the surgery cost based on its published fee schedule, as Mr C's fees exceeded the schedule limits. Mrs S also complained about lack of clarification regarding overnight hospital stay coverage and delayed responses from Aviva. The ombudsman found that Aviva's fee schedule approach is standard practice and was clearly communicated to Mrs S on multiple occasions, and that the policy clearly covered hospital accommodation. While acknowledging some communication delays, the ombudsman determined that the £100 compensation already paid was appropriate and did not uphold the complaint.

The Ombudsman's reasoning

The ombudsman found that Aviva's use of a fee schedule is a standard and fair commercial practice in private medical insurance, provided it is applied consistently. Aviva had clearly communicated on multiple occasions that Mr C's fees exceeded the schedule and that Mrs S would face shortfalls. The policy clearly stated that hospital accommodation would be covered, and it was Mrs S's responsibility to read the policy documents. While Aviva was slow to respond to some queries, this did not constitute unfair or unreasonable handling of the claim. The £100 compensation already offered appropriately reflected the inconvenience caused by delayed responses.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website