Upheld: claims handling, coverage decision, communication failure complaint against Vitality Health Limited

Decision detail

Summary

Mrs I complained that Vitality Health Limited declined to cover a fourth spinal injection at an out-of-network hospital, despite having previously authorised four injections under the spinal network pathway. Vitality initially refused cover citing lack of chronic condition management coverage, but subsequently agreed to authorise the fourth injection and offered £200 compensation. Mrs I disputed this, arguing that Vitality had not clearly communicated the four-injection limit and that she should receive full ongoing coverage for her consultant's recommended treatment. The ombudsman upheld the complaint, finding that while Vitality had only authorised four injections and did not retrospectively change cover, it failed to communicate this limitation effectively and caused unnecessary delays and distress. The ombudsman determined that Vitality's offered £200 compensation and authorisation of the fourth injection was fair and reasonable, but could not award compensation for claimed private treatment costs or lost earnings without supporting evidence.

The Ombudsman's reasoning

The ombudsman found that Vitality had only ever authorised four spinal or joint injections and therefore did not retrospectively withdraw or change cover. However, Vitality failed to effectively communicate this limitation in subsequent correspondence and phone calls. The ombudsman acknowledged that Vitality's handling of the claim caused distress and inconvenience through poor communication and delayed authorisation of the fourth injection. The £200 compensation offered was deemed reasonable to acknowledge these errors, though the ombudsman could not award compensation for claimed private treatment costs or loss of earnings as no evidence was provided.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website