Upheld: unreasonable claim decline / unfair claim handling complaint against Vitality Health Limited
Financial Ombudsman decision DRN-6316935 of 2026-04-28T00:00:00+00:00. unreasonable claim decline / unfair claim handling complaint against Vitality Health Limited. Outcome: Upheld.
Decision detail
| Reference | DRN-6316935 |
|---|---|
| Decision date | 2026-04-28T00:00:00+00:00 |
| Firm | Vitality Health Limited |
| Product | private medical insurance |
| Claim type | unreasonable claim decline / unfair claim handling |
| Outcome | Upheld |
| Remedy | Vitality Health Limited is required to: (1) Reimburse the estate of Miss C the cost of treatment for the June 2024 and July 2024 psychiatrist appointments and her admission to the mental health clinic; (2) Pay 8% per year simple interest on these amounts calculated from the date the expenses were incurred to the date they are reimbursed; (3) Pay the estate of Miss C £350 compensation. |
Summary
Miss C, covered under a group private medical insurance policy with a moratorium clause, sought to claim for mental health treatment in June 2024 but Vitality declined based on her disclosure of previous therapy in 2019/2020. In August 2024, as Miss C sought inpatient mental health treatment, Mrs C provided additional information clarifying the previous appointment was in 2018, was for a relationship break-up, and was with a life coach, while Miss C's psychiatrist stated they did not believe the current treatment was pre-existing. Vitality maintained its decline and the policy ended on 6 August 2024; Miss C took her own life that evening. The ombudsman found Vitality's initial decline was not unreasonable but should have been reconsidered in August 2024 with further investigation. The ombudsman upheld the complaint, requiring Vitality to reimburse all treatment costs with 8% interest and pay £350 compensation for service failures and unfair handling, though noting the outcome of further investigation could not be determined.
The Ombudsman's reasoning
The ombudsman found that Vitality's initial June 2024 decline was not unreasonable based on Miss C's disclosure that she had seen a therapist after feeling low, as this fell within the five-year pre-policy period and could constitute a related condition under the moratorium clause. However, the ombudsman concluded that in August 2024, when Mrs C provided clarifying information (that the previous appointment was in 2018, was for a relationship break-up, and was with a life coach not a therapist) and Miss C's psychiatrist stated they did not believe the current treatment was pre-existing, Vitality should have sought further information from Miss C's treatment providers to properly reconsider the claim. The ombudsman acknowledged that while Vitality could have requested further information, it would not have been able to obtain and review it before Miss C's death, and the outcome of such a review could not be determined. Given Vitality's agreement to reimburse all treatment costs and the complexity of the medical situation, the ombudsman considered £350 compensation reasonable for the distress caused by Vitality's errors (failed callbacks, failure to log complaint) and the unreasonable handling in August 2024, though not sufficient to conclude the outcome would have been different.
How this compares
| Group | Decisions | Uphold rate |
|---|---|---|
| Vitality Health Limited, all decisions | 491 | 26% |
Source
Read the original decision on the Financial Ombudsman Service website