Not upheld: Travel / life insurance claim disputes complaint against Vitality Health Limited

Decision detail

Summary

Mr R complained on behalf of his son Master R that Vitality Health Limited unfairly rejected a claim for diarrhoea under a private health insurance policy by applying the moratorium term for pre-existing conditions. Vitality argued the symptoms pre-dated the 1 November 2025 policy start date and agreed to cover costs up to diagnosis. Mr R contended the symptoms were not clinical evidence and that the GP had considered previous loose stools normal. The ombudsman upheld Vitality's position, finding that medical records from two GPs documented loose stools for approximately two months prior to the policy start date, which satisfied the moratorium term's requirement that symptoms existed before cover started, regardless of whether they were clinically recorded at the time or considered normal.

The Ombudsman's reasoning

The ombudsman found that the moratorium term only requires one of three conditions to be met (medical treatment, symptoms, or awareness), not all three. Medical evidence from two GPs documented that Master R had loose stools for approximately two months before the policy started (around September 2025), which falls within the five-year pre-existing condition window. The ombudsman rejected the argument that symptoms must be clinically recorded at the time of occurrence or that the GP's view of normality was relevant. The moratorium term was fairly applied as Master R had documented symptoms prior to the 1 November 2025 policy start date.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website