Not upheld: claim decline / policy limit application / fair treatment of vulnerable consumer complaint against BUPA Insurance Limited

Decision detail

Summary

Mr N, a vulnerable consumer with complex mental health needs, requested that BUPA bring forward his policy renewal date after exhausting his annual mental health inpatient treatment allowance (28 days) in January 2026. He sought this flexibility to access a 28-day private treatment facility stay, arguing BUPA's refusal could cause him foreseeable harm. BUPA declined, citing policy year structure and system limitations. The ombudsman found BUPA acted fairly in declining the request, as the policy terms clearly set out annual limits applying to each 12-month period, and vulnerability does not entitle a consumer to additional benefits beyond those contracted. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that whilst BUPA must treat vulnerable consumers fairly under the Consumer Duty and ICOBS, this does not require the firm to set aside its policy terms or allow early access to the next policy year's benefits. The policy clearly defines annual limits that apply to each 12-month policy year, and Mr N has accepted he has met the limit for the current year. Although Mr N is vulnerable, vulnerability does not qualify him for additional benefits beyond those contracted for in the policy terms. BUPA reasonably considered and declined the request, and was entitled to rely on the policy terms to do so fairly.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website