Not upheld: claim handling delay and unfair claim decline complaint against Vitality Health Limited

Decision detail

Summary

Miss E complained to Vitality Health Limited about delays in processing her claim for outpatient treatment following an emergency hospital admission for pancreatitis in July 2025, and about the unfair decline of her hospital cash benefit claim. Vitality acknowledged causing a three-week delay by not initially explaining that additional information was needed, and paid £75 compensation. The ombudsman found the compensation reasonable, upheld the decline of the hospital cash benefit claim based on the emergency admission exclusion in the policy, and found the outpatient claim was reasonably declined because Miss E did not provide the required Claims Information Request form and GP referral letter needed for claim validation.

The Ombudsman's reasoning

The ombudsman found that while Vitality's failure to explain the information requirements caused a three-week delay, this was not a significant delay in the circumstances and £75 compensation was reasonable. The hospital cash benefit claim was properly declined under the policy exclusion for emergency admissions. The outpatient claim was reasonably declined because Miss E failed to provide the necessary CIR form and GP referral letter required for claim validation, which Vitality needed to review medical records and determine eligibility. No medical evidence supported Miss E's claim that the delay worsened her health condition.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website