Not upheld: claim rejection based on chronic condition exclusion complaint against Vitality Health Limited

Decision detail

Summary

Mrs T claimed that Vitality Health Limited unfairly refused to cover 24 chiropractic sessions for a degenerative condition, covering only 16 sessions instead. Vitality relied on a policy exclusion for chronic conditions. The ombudsman found that Vitality reasonably applied the chronic condition exclusion based on medical evidence showing the patient was not responding quickly to treatment (0-50% progress over 12 sessions) and the chiropractor's own indication that treatment would transition from acute pain management to maintenance. Although the policy terms do not specify a session limit, the ombudsman considered this reasonable given the need to assess individual circumstances across a wide range of medical conditions. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman concluded that Vitality reasonably applied the chronic condition exclusion based on medical evidence showing the condition was degenerative and the patient was not responding quickly to treatment. The chiropractor's own statement that treatment would move from acute pain management to maintenance phase supported Vitality's decision to limit cover. Although the policy terms do not specify a session limit, this is reasonable given the wide range of medical conditions covered and the need to assess individual circumstances.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website