Partially upheld: claims handling failure and information requests complaint against BUPA Insurance Limited

Decision detail

Summary

Mr B claimed for composite bonding dental treatment under his BUPA group dental insurance policy, providing a letter from his Specialist Orthodontist stating it was for health reasons. BUPA requested additional information including x-rays/scans and dentist notes to verify the treatment was clinically necessary rather than cosmetic. Mr B believed BUPA was unreasonably delaying his claim. The ombudsman found BUPA's request for additional information was fair and reasonable under insurance principles and policy terms, but upheld the complaint regarding BUPA's failure to respond to several emails, awarding £125 compensation in addition to £75 already paid.

The Ombudsman's reasoning

The ombudsman found that BUPA was entitled to request additional information (x-rays/scans and dentist notes) to verify that the treatment was clinically necessary rather than cosmetic, as this is a standard insurance principle and the policy terms permitted such requests. The letters from the Specialist Orthodontist alone were insufficient to satisfy BUPA's reasonable investigation requirements. However, BUPA's failure to respond to several of Mr B's emails constituted a claims handling failure for which compensation was appropriate. The ombudsman rejected Mr B's assertions that BUPA had intentionally delayed the claim or provided contradictory justifications.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website