Financial Ombudsman highlights PMI and protection claims

clock

The Financial Ombudsman (FOS) has published case studies of typical private medical insurance (PMI) and protection claims to illustrate the type of claims it has received.

In newsletter 117, the FOS said "Complaints about health and medical insurance can be some of the most sensitive and hardest-fought that we see - as well as some of the most challenging to resolve."

The FOS said it tended to see similar issues and themes in the cases referred, such as whether a procedure is covered by a policy or whether the policyholder's condition meets the policy's definition.

Additionally, the FOS said it saw complaints for consumers who found that a new policy didn't provide the same cover levels as a previous policy. The body would intervene by looking into how the policy was sold to the consumer.

In one case study, the FOS explained it would have upheld a complaint where a claimant with breast cancer had a second operation rejected by her PMI insurer.

The insurer in this scenario had said they would cover "initial reconstructive surgery" only.

However the claim was upheld by FOS after consulting the claimants plastic surgeon who explained her surgery was not separate, it was part of one reconstructive procedure.

In another scenario, a claimant's critical illness claim was rejected as after being put on a waiting list for coronary bypass surgery, his ten year critical illness policy had expired. The claimant had understood - from reading the policy booklet he'd been sent - that because the policy was still active when he was put on the waiting list, his claim would be met.

In this scenario, FOS deemed the insurer's policy wording - "the claimant must suffer from one of the conditions defined under ‘Conditions covered', provided they survive until the 14th day from the date of diagnosis, surgery or being added to a waiting list" to be ambiguous; and the complaint was upheld.

More on Regulation

Most firms unable to meet bereavement claims performance levels: FCA

Most firms unable to meet bereavement claims performance levels: FCA

Call for improved bereavement handling times

Cameron Roberts
clock 22 November 2024 • 3 min read
Record-high receipts for IPT and employer NICs

Record-high receipts for IPT and employer NICs

HMRC data

Cameron Roberts
clock 21 November 2024 • 2 min read
Chancellor targets FOS modernisation and FCA consultation

Chancellor targets FOS modernisation and FCA consultation

Consultation part of the advice guidance boundary review

Isabel Baxter
clock 15 November 2024 • 3 min read

Highlights

COVER Survey: Advisers damning of protection insurer service levels

COVER Survey: Advisers damning of protection insurer service levels

"It takes longer than ever to get underwriting terms"

John Brazier
clock 12 October 2023 • 5 min read
Online reviews trump price for young people selecting life and health cover

Online reviews trump price for young people selecting life and health cover

According to latest ReMark report

John Brazier
clock 11 October 2023 • 2 min read
ABI members with staff neurodiversity policy nearly doubles

ABI members with staff neurodiversity policy nearly doubles

Women within executive teams have grown to 32%

Jaskeet Briah
clock 10 October 2023 • 3 min read