Not upheld: claims handling and policy coverage interpretation complaint against Vitality Health Limited

Decision detail

Summary

Ms P complained about Vitality Health Limited's refusal to cover specialist physiotherapy treatment with her preferred non-recognised provider, claiming the policy terms were unclear and ambiguous. Vitality had offered £300 compensation for service failures and delays in handling her claim. The ombudsman found the policy clearly required treatment to be provided by Vitality-recognised professionals and that Vitality had communicated this requirement to Ms P, offering a reasonable alternative. The ombudsman upheld the £300 compensation award but rejected Ms P's claim for contribution towards the £760 treatment costs, finding the policy terms fair, clear and not misleading.

The Ombudsman's reasoning

The ombudsman found that the policy wording clearly requires treatment to be provided by professionals recognised by Vitality, not just HCPC-registered professionals. The distinction between 'in-network' (direct billing arrangement) and 'out-of-network' (no direct arrangement but may still be recognised) providers was explained. The policy clearly states that treatment with non-recognised professionals is excluded from cover. Vitality communicated this clearly to Ms P and offered a reasonable alternative. The ombudsman noted that limiting cover to recognised professionals is standard practice among private medical insurers.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website