Not upheld: policy exclusion and underwriting decision complaint against Vitality Health Limited

Decision detail

Summary

Mr I complained that Vitality Health Limited unreasonably retained a personal exclusion on his private medical insurance policy for pigmented lesions on his retina and related conditions, and refused his 2025 request to remove it. The exclusion was originally added in 2017 when he was referred for investigation into hypertrophic pigment lesions, though he reported no treatment, symptoms, or follow-up since 2021. Vitality reworded the exclusion from 'eye floaters and related conditions' to 'pigmented lesions on retina and related conditions' for clarity. The ombudsman found the condition to be an abnormal finding that Vitality could reasonably assess and exclude, that the revised wording more accurately reflected the clinical context, and that including related conditions was standard practice. The complaint was not upheld.

The Ombudsman's reasoning

Although Mr I's eye condition is benign and stable with no current symptoms or monitoring since 2021, it remains an abnormal finding. Vitality is entitled to assess the impact of this condition on cover and can reasonably add an exclusion. The revised wording more accurately describes the condition and its clinical context than the original wording. The inclusion of 'related conditions' is standard insurance practice and was present in the original exclusion, so Vitality has not unfairly extended the scope. Vitality, exercising commercial discretion, can reasonably decide what level of risk it is prepared to accept.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website