Upheld: unfair claims handling and poor communication complaint against Vitality Health Limited

Decision detail

Summary

Mr and Mrs T complained about Vitality Health Limited's handling of a private health insurance claim for cataract surgery. Mrs T submitted a claim, underwent NHS cataract surgery in November 2024, and provided medical evidence confirming the surgery date when returning claim forms. However, Vitality failed to identify that the surgery had already occurred and continued requesting unnecessary information, ultimately authorising an unnecessary consultation appointment in January 2025 for which Mrs T paid a £100 excess. The ombudsman upheld the complaint, finding that Vitality should have promptly recognised the surgery had occurred and provided clear guidance about alternative claims, thereby avoiding the confusion and inconvenience experienced by Mr and Mrs T. Vitality was directed to pay £300 compensation for distress and inconvenience and reimburse the £100 excess with interest.

The Ombudsman's reasoning

While Vitality fairly requested additional information initially to verify coverage and rule out pre-existing conditions, the firm failed to identify that Mrs T had already undergone NHS cataract surgery when she provided medical evidence confirming this. This oversight caused Vitality to continue requesting unnecessary information and ultimately authorise an unnecessary consultation appointment. The ombudsman found that had Vitality promptly recognised the surgery had occurred, it would have provided clear guidance about alternative claims (NHS cash benefit and optical reimbursement) and avoided the confusion and inconvenience experienced by Mr and Mrs T. The £100 excess paid for the unnecessary consultation should not have been incurred and should be reimbursed.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website