Not upheld: claim denial and policy cancellation backdating complaint against Bupa Insurance Limited

Decision detail

Summary

Ms I complained that Bupa Insurance Limited unfairly declined to pay for private health insurance treatment that occurred between 12 October and 12 November 2025, despite pre-authorising treatment on 21 October 2025. Her employer cancelled the policy on 12 November 2025 but backdated the cancellation to 12 October 2025, and Ms I was not informed of this backdating. The ombudsman found the complaint not upheld because Bupa was unaware of the cancellation or backdating until 12 November 2025, the policy terms explicitly exclude post-cancellation treatment even if pre-authorised, and Bupa followed the employer's instructions. Bupa agreed to pay for treatment on 12 November 2025 as a gesture of goodwill.

The Ombudsman's reasoning

The ombudsman found that Bupa acted fairly and reasonably because: (1) the policy was a contract between the employer and Bupa, with Ms I as a beneficiary; (2) Bupa was not notified of the cancellation or backdating until 12 November 2025, so it reasonably pre-authorised treatment before that date; (3) the policy terms explicitly state that cover does not extend to treatment after the cover end date, even if pre-authorised; (4) Bupa followed the employer's instructions to backdate the cancellation to 12 October 2025; and (5) Bupa's gesture of goodwill to pay for treatment on 12 November 2025 was fair.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website