Not upheld: claims handling delays and customer service failures complaint against Vitality Health Limited

Decision detail

Summary

Mrs A complained to Vitality Health Limited about service failures when attempting to claim on her group private medical insurance policy for a breast cancer-related procedure. After receiving an unexpected NHS cancellation slot in mid-April 2025, Mrs A contacted Vitality to determine coverage options but ultimately underwent the procedure on the NHS rather than privately. Mrs A claimed Vitality failed to log her complaints, provide callbacks, and process her claim promptly, and argued she should have been authorized for private treatment. The ombudsman found that while Vitality had minor service failures, the complexity of the claim and the tight timeline meant private treatment authorization was unlikely before the surgery date, and Mrs A would probably have proceeded with NHS treatment regardless. The ombudsman upheld Vitality's offer of £200 compensation for service failures but rejected Mrs A's claim for higher compensation or private treatment coverage.

The Ombudsman's reasoning

The ombudsman found that while Vitality had service failures in complaint handling and minor delays, these did not cause Mrs A to lose private treatment. The claim was complex and required specialist input, making it reasonable for Vitality to request written information. Although Vitality unnecessarily asked the consultant for further information about NHS eligibility criteria (which they later acknowledged was unnecessary), even if they had responded within standard timescales, the surgery would likely have already occurred. The ombudsman was not persuaded that Mrs A would have foregone NHS treatment given the two-year waiting list, her symptoms, and the proximity of the planned date. The £200 compensation fairly reflected the distress and inconvenience caused by service failures, but not the claimed £12,000 loss.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website