Not upheld: claim handling failure and service standards breach complaint against Vitality Health Limited

Decision detail

Summary

Mrs G and Mr J complained about Vitality's handling of a healthcare insurance claim following Mrs G's diagnosis with placenta praevia during pregnancy in June 2025. Vitality made multiple errors over several months, including failing to promptly decline the claim and providing incorrect information, before finally declining it on 3 November 2025. Vitality partially upheld the complaint and paid £250 compensation plus £50 for GP costs. The ombudsman found the claim was fairly declined because placenta praevia was not listed as a covered pregnancy complication in the policy terms, and the compensation already offered was appropriate for the service failures. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that while Vitality's service was deficient with multiple errors over several months, the decision to decline the claim was fair because placenta praevia was not a covered condition under the explicit policy terms. The ombudsman reasoned that an insurer is entitled to decide what is and isn't covered, and the policy clearly listed only specific pregnancy complications. Although incorrect information was given, this did not justify paying a claim outside policy terms. The ombudsman was not persuaded Mrs G and Mr J would have acted differently had they known the truth, as Mrs G received necessary NHS treatment regardless. The compensation already offered (£250 for distress and £50 for GP costs) was deemed appropriate for the service failures.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website