Not upheld: Other regulated complaint complaint against Health Shield Friendly Society Limited

Decision detail

Summary

Mr O complained that HSFS unfairly declined to pay £67 of a medical claim for a 'Phlebotomy Service Charge' on the basis it was an administrative charge excluded under the policy. The investigator contacted the provider and confirmed the charge related to blood collection, after which HSFS agreed to pay. The ombudsman found the invoice terminology ambiguous enough to justify HSFS's initial decline, as 'service charge' could reasonably suggest an administrative fee rather than a clinical procedure cost. The policy required clear cost breakdowns and placed responsibility on the policyholder to obtain supporting information. Although not upholding the complaint, the ombudsman ordered HSFS to make the payment it had agreed to.

The Ombudsman's reasoning

The ombudsman found that the term 'Phlebotomy Service Charge' lacked sufficient clarity to definitively establish whether it was a clinical procedure cost or an administrative charge. The policy explicitly excludes administrative charges and requires policyholders to provide clear cost breakdowns. While sympathetic to Mr O's position, the ombudsman considered HSFS's initial decline reasonable and its offer to reconsider upon clarification appropriate. The policy terms placed responsibility on the policyholder to obtain supporting information. However, since HSFS had agreed to pay the amount following clarification, that payment must be made.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website