Not upheld: mis-selling / failure to disclose specialist coverage limitations complaint against Mercer Limited trading as Mercer Marsh Benefits

Decision detail

Summary

Mr A complained that Mercer misled him into purchasing private medical insurance by implying his preferred specialist was covered by the policy, when in fact the specialist was not part of the insurer's fee approved network. During the 2023 non-advised sale, Mercer stated it could not confirm specialist availability and explained that insurers only provide hospital lists. Mr A assumed his specialist would be covered because the hospital was within the scope of cover. The ombudsman found that Mercer adequately communicated its limitations and that Mr A should have verified specialist coverage with the insurer directly. The complaint was not upheld as Mercer fulfilled its obligations in a non-advised sale by providing available policy options and necessary sales documents.

The Ombudsman's reasoning

As this was a non-advised sale, Mercer's responsibility was to offer available policies and provide sufficient information for Mr A to make his own decision, not to verify specialist coverage. The ombudsman found that Mercer clearly communicated it could not confirm specialist availability and explained that insurers only provide hospital lists. Mr A's assumption that his specialist would be covered because the hospital was in the network was not a reasonable basis for complaint, as specialist coverage does not automatically follow from hospital coverage. The ombudsman concluded that Mr A should have directed questions about specialist coverage to the insurer rather than relying on Mercer to provide that information.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website