Not upheld: claim declined - preventative treatment exclusion complaint against Vitality Health Limited

Decision detail

Summary

Mrs A claimed on her private medical insurance policy for tests following a raised cholesterol reading. Vitality initially declined the claim as preventative, but after Mrs A challenged this, agreed to cover two specialist consultations and one laboratory test. Mrs A subsequently underwent additional unauthorised tests (blood pressure monitoring, ECG, echo, and CT coronary angiogram) and complained when Vitality declined to cover these costs. The ombudsman found the additional tests were preventative in nature and not covered by the policy terms, and that Vitality had adequately clarified what it would cover before Mrs A proceeded with treatment.

The Ombudsman's reasoning

The ombudsman found that Vitality reasonably declined the claim because the treatment was preventative in nature and not covered by the policy terms. While Vitality could have been clearer initially about what 'laboratory test' meant, it adequately clarified its position on 20 February before Mrs A underwent treatment. The additional tests (blood pressure monitoring, ECG, echo, CT coronary angiogram) were all for risk assessment purposes without evidence of an acute medical condition, making them preventative and therefore not eligible under the policy.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website