Health Insurance

An insurer must act on a valid cancellation request from the policyholder or their authorized representative without unreasonable delay.

Insurers must communicate information to consumers which is clear, fair and not misleading, in compliance with FCA rules and Consumer Duty principles.

An insurer must ensure a policy is suitable for the consumer's demands and needs and provide sufficient information for informed decision-making, particularly regarding pre-existing medical conditions.

An insurance intermediary must ensure a recommended policy is suitable for the consumer's demands and needs, and provide sufficient information to allow the consumer to make an informed decision.

An advised sale of insurance must be suitable for the consumer's needs, with clear disclosure of significant differences from their existing cover.

The complaint Mrs S complains that AXA PPP Healthcare Limited applied an exclusion retrospectively under her private health insurance policy and declined a claim as a result of this. What happened Mrs S has been represented by Mr S. He call

An insurer must handle policy enrollment requests clearly and accurately, providing proper explanation of underwriting terms and conditions before acceptance.

Insurers must act fairly, honestly and professionally in accordance with best interests of customers, and avoid causing foreseeable harm when taking action such as policy cancellation.

Insurers must not unreasonably decline claims and must rely on reliable medical evidence, such as endoscopy results, to establish pre-existing conditions.

Insurers must handle claims fairly and not unreasonably reject claims; when relying on policy exclusions, the insurer must demonstrate the exclusion applies and show fair, consistent treatment of similarly situated policyholders.

An insurance provider selling an advised basis policy must ensure it is suitable for the consumer's circumstances and provide sufficient information about coverage limitations.

An insurer must apply policy terms consistently and provide clear communication when changing its position on coverage, even when the policy wording itself restricts cover to NICE-approved treatments.

When claims are received on the same day for related treatment, the excess should be applied fairly based on the chronological order of treatment received rather than invoice receipt order, particularly where this significantly impacts the

An insurer must take reasonable care to collect premiums upon policy renewal and notify the customer of payment failures, and must offer fair payment arrangements for arrears caused by its error.

An insurer is not responsible for the availability of consultants on its approved list, but must handle cancellations properly and provide reasonable service support.

An insurer must handle claims fairly and in accordance with policy terms, which clearly distinguish between counselling (excluded from outpatient limits) and other mental health treatments like CBT (subject to outpatient limits and excess).

Insurers must provide clear, fair and not misleading information about policy changes at renewal, and must handle claims fairly without unreasonably rejecting them.

An insurer can reasonably decline a claim where the policyholder has exceeded the specified benefit limit, even if the insurer initially approved the treatment.

The Financial Ombudsman Service lacks jurisdiction to consider discretionary payments made by an employer from their own funds rather than from insured funds under a regulated contract of insurance.

A non-advised insurance sale must provide sufficient information to enable an informed decision, but the insurer is not responsible for suitability if the consumer was given clear information about cover options.

Under CIDRA 2012, an insurer can apply exclusions for a qualifying misrepresentation if the consumer failed to take reasonable care in disclosing pre-existing medical conditions, provided the insurer would have offered different terms had d

An insurer may reasonably decline a claim where the treatment location falls outside the policy's hospital list and no contractual exception applies.

A group health insurance provider is not obligated to notify individual members directly of policy cancellation when it communicates administrative matters only with the employer as the policyholder.

An insurance provider is not unreasonably required to approximate treatment costs or proactively ensure a policyholder stays within policy limits; the policyholder bears responsibility for verifying compliance with known limits before commi

An insurer may fairly rely on a policy's preventative treatment exclusion to decline claims where the treatment is primarily focused on preventing future disease through health improvement measures.

Insurers must handle claims promptly and fairly without declining claims unreasonably, and compensation for distress caused by delays must be reasonable in proportion to the impact.

Insurance policies covering pregnancy and childbirth are limited to treatment of medical conditions arising during pregnancy, not routine or preventative childbirth procedures.

Private medical insurers may decline claims for treatment provided by specialists outside their approved network, even if the treatment type is covered, provided the policyholder was given clear notice of this requirement and instructions t

An advisor must provide suitable advice based on information actually disclosed by the consumer during the application process, and is entitled to rely on that disclosed information.

Under CIDRA 2012, an insurer may add a retrospective exclusion for a qualifying careless misrepresentation where the consumer failed to disclose material medical investigations within the relevant disclosure period.

An insurer may apply chronic condition exclusions under a group private medical insurance policy where treatment requires ongoing monitoring and management, even if the condition has a planned treatment endpoint.

An insurer may apply chronic condition exclusions to ongoing treatment that extends beyond the acute phase, provided reasonable notice is given and the policy terms clearly define what constitutes a chronic condition.

An advised insurance sale requires the seller to ensure the recommended policy is suitable for the consumer's circumstances and needs at the time of sale.

Compensation for insurance claim mishandling must be fair and proportionate to the actual impact of the business mistake, not the underlying medical condition or loss of expectation alone.

Private medical insurance policies may legitimately exclude cover for chronic conditions as defined in the policy terms, and insurers are entitled to assess claims against those policy definitions.

A financial adviser must conduct business with due skill, care and diligence, provide clear and fair information, and ensure suitability by exploring the customer's medical history.

An insurer is entitled to assess claims against its policy definitions of chronic conditions, and a policy exclusion for chronic conditions is a standard and fair term in private medical insurance.

A pre-existing condition exclusion clause in a health insurance policy fairly applies where the insured had symptoms of the condition before the policy start date, even if the condition was not then diagnosed.

Private medical insurance policies are designed to cover acute conditions but not chronic conditions, and insurers may impose limitations when a condition meets the contractual definition of chronic.

A moratorium underwriting clause in a private medical insurance policy excludes cover for any condition where symptoms existed before the policy start date, regardless of whether a formal diagnosis was made at that time.