Not upheld: claims settlement and coverage decision complaint against Vitality Health Limited

Decision detail

Summary

Mrs R, on behalf of Mr R's estate, complained that Vitality Health Limited unfairly refused to fully cover DEXA mini beam treatment costs for Mr R's rare form of cancer, offering only a discretionary contribution of £10,281.60. Vitality agreed to cover the subsequent stem cell transplant but declined the DEXA mini beam treatment as it was not established medical practice in the UK. The ombudsman found Vitality's decision was reasonable based on the policy terms and the specialist's own evidence confirming the treatment relied on anecdotal experience rather than standard therapies. Although Vitality acknowledged handling errors and offered £400 compensation, the ombudsman upheld this as fair and did not require additional payment beyond the discretionary contribution already offered.

The Ombudsman's reasoning

The ombudsman found that Vitality's policy terms clearly state the insurer does not generally cover treatment that is not established medical practice in the UK or approved for general use in the NHS. The specialist's own evidence confirmed DEXA mini beam treatment was not a standard therapy and relied on anecdotal experience. While acknowledging the multi-disciplinary team's recommendation, the ombudsman concluded Vitality reasonably determined the treatment was not covered under the policy terms. The discretionary contribution offered was fair. The £400 compensation for the delay in clinical review was proportionate.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website