Not upheld: unfair claim decline under moratorium clause complaint against Vitality Health Limited trading as VitalityHealth

Decision detail

Summary

Mr S held a private medical insurance policy with Vitality starting August 2024 under moratorium underwriting terms. He made a claim in 2025 for left knee surgery due to osteoarthritis, but Vitality declined it after the GP confirmed symptoms predated the policy start date. Mr S disputed the link between his meniscal injury and osteoarthritis, but the ombudsman found Vitality's reliance on the GP's medical history and application of the moratorium clause was fair and reasonable. The ombudsman also found no evidence of unreasonable delay in claim handling and noted Vitality appropriately handled a separate data breach incident.

The Ombudsman's reasoning

The moratorium clause clearly excludes treatment for pre-existing conditions or related conditions where symptoms existed in the five years before cover started. The GP's confirmation that Mr S had symptoms and a meniscal injury before the policy start date in August 2024 meant the claim fell within the exclusion. It was not unreasonable for Vitality to link the meniscal injury to osteoarthritis based on the medical history provided by the GP. Vitality was entitled to rely on the information presented and processed the claim without unreasonable delay.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website