Not upheld: claim denial based on personal medical exclusion complaint against Vitality Health Limited

Decision detail

Summary

Mr and Mrs C complained that Vitality unfairly declined Mrs C's claim for bilateral hip replacement surgery, arguing the policy was underwritten on a moratorium basis and Mrs C had been symptom-free for over two years. Vitality declined the claim because the personal exclusion for osteoarthritis did not fall within the moratorium scope and would not have been removed due to the chronic nature of the condition. The ombudsman found the claim denial was fair and in line with policy terms, as medical evidence showed Mrs C's osteoarthritis was ongoing and under investigation since policy inception in 2020, meaning she never satisfied the moratorium's two-year symptom-free requirement. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that Vitality fairly declined the claim because it was in line with the policy exclusion terms. The personal exclusion for osteoarthritis did not fall within the moratorium clause scope. Even if the moratorium applied, Mrs C would not have satisfied its criteria because medical evidence shows her osteoarthritis was chronic, progressive, ongoing, and under investigation since 2020, meaning she was never symptom-free for the required continuous two-year period. Vitality's refusal to retrospectively lift the exclusion was fair given the chronic and degenerative nature of the condition.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website