Not upheld: claim declined - pre-existing condition exclusion complaint against Western Provident Association Limited (trading as WPA)

Decision detail

Summary

Mr D complained that WPA unfairly declined his private medical insurance claim for NHS Cash Benefit, arguing that WPA used hindsight to determine his lymphoma was pre-existing. WPA declined the claim based on moratorium underwriting terms excluding conditions with symptoms present in the five years before the policy start date. The ombudsman found that clinical evidence confirmed Mr D had back pain and other symptoms for months prior to the September 2022 policy start date, which were subsequently confirmed as lymphoma-related. The ombudsman concluded the decline was reasonable and fair under the policy terms, as the test is whether symptoms existed, not whether they could have been identified as lymphoma-related at the time. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman applied the test of whether any symptoms of the condition being claimed for existed prior to the policy start date, whether diagnosed or not. The test is not whether it could have been known the symptoms were lymphoma-related, but whether symptoms existed. Based on clinical evidence showing back pain for months prior to start date and the consultant's confirmation that these symptoms were linked to the lymphoma diagnosis, the ombudsman concluded it was reasonable for WPA to decline the claim in line with the moratorium policy terms.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website