Not upheld: Service failures generally complaint against Vitality Health Insurance Limited

Decision detail

Summary

Mr D complained that Vitality Health Insurance Limited failed to cover the full cost of his counselling treatment under his employer's group private medical insurance policy. Mr D was initially referred to Vitality's partner service C, which authorised eight sessions at £120 each. When C incorrectly stated no further sessions could be authorised, Mr D arranged self-pay treatment at £45 per session and asked Vitality to reimburse him. Vitality approved eight further sessions based on incorrect information from Mr D about how many sessions he had already received, which caused him to exceed his £1,000 annual limit. The ombudsman found that while Vitality should have verified the information against its records, Mr D benefited from the error and was not entitled to further payment. The ombudsman also rejected Mr D's complaint about the referral to C, finding it reasonable given that counselling is not covered under the policy.

The Ombudsman's reasoning

The ombudsman found that both parties were at fault. Mr D provided incorrect information about the number of sessions he had received through C and had responsibility to stay within his limit. However, Vitality could have verified the information by checking its records of payments to C and would have discovered that authorising eight further sessions would exceed the limit. Despite these errors by Vitality, Mr D benefited from them by receiving more sessions than his remaining limit would have allowed, so no further payment was warranted. Regarding the referral to C, the ombudsman found this was reasonable as counselling is not covered under the policy and was only provided as a concession through C.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website