Vitality Health Limited · DRN-5862869

The complaint Ms B complains Vitality Health Limited unfairly turned down her claim for right knee surgery. What happened Ms B holds a joint private medical insurance policy together with her partner. The policy is underwritten by Vitality. It was first taken out in May 2024 and included moratorium underwriting terms as follows. “We don’t pay claims for the treatment of any medical condition or related condition which, in the five years before your cover started: • you have received medical treatment for, or • had symptoms of, or • asked advice on, or • to the best of your knowledge and belief, were aware existed. This is called a ‘pre-existing’ medical condition. However, subject to the plan terms and conditions, a pre-existing medical condition can become eligible for cover providing you have not: • consulted anyone (e.g. a GP, dental practitioner, optician or therapist, or anyone acting in such a capacity) for medical treatment or advice (including check-ups), or • taken medication (including prescriptions or over-the counter drugs, medicines, special diets or injections) for that pre-existing medical condition or any related condition for two continuous years after your cover start date.” In December 2024, Ms B experienced issues with her right knee and was referred to a consultant. And the consultant confirmed she needed surgery. So Ms B contacted Vitality to make a claim. Vitality requested Ms B’s medical records, and after reviewing these, said the claim was not covered as the right knee condition was pre-existing during the moratorium period. In the five years prior to the policy start date, Ms B’s medical records show the following symptoms and consultations in relation to her right knee. February 2023 • Ms B reported severe pain in her right knee to her GP

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• The GP referred Ms B to a consultant – they said Ms B had a previous knee replacement and may need further surgery. They stated “The knee is painful and tender and she is unable to weight bear”. • Ms B saw a consultant and their letter reflects the following: “…she has been really struggling with her right ankle, where she is awaiting ankle replacement surgery and has been walking with a quite externally rotated gait pattern. This would tend to exacerbate patellofemoral subluxation problems and would also be putting increased load on the medial retinaculum and the medial structures of the knee.” “…if she has persistent problems with the knee, there are soft tissue procedures we could consider to stabilise the patellofemoral joint…” November 2023 • Ms B saw the GP and reported “right revision total knee replacement August 2014 is causing pain when moving and when I sleep”. • She is noted to have said this had been ongoing for a long time, and that she “had an ankle fusion operation in May in the hope that it would help my gait” December 2023 • Ms B saw a consultant in relation to both knees • In a follow-up letter the consultant said: “she has been noticing a pain in the medial calf area” “she is also recovering reasonably well from right ankle fusion […] about seven months ago.” “right knee examination showed slightly exaggerated valgus alignment with mild swelling” • Both of Ms B’s knees were x-rayed. In regard to the right knee and earlier revision the consultant stated “no suggestion of any complications”. Ms B told Vitality the pain she experienced in her right knee in February 2023 was a consequence of an issue with her right ankle, which was subsequently operated on May 2023. And she provided letters from her consultant. Vitality said it’d reviewed the consultant letters, but still thought the claim should be declined as Ms B had been experiencing symptoms with her right knee and had sought medical advice during the moratorium period. Ms B complained to Vitality. It maintained it had been correct to decline the claim as it said Ms B had not met the terms of the moratorium as her condition was pre-existing, and she’d not had a clear two year period after the policy started. Unhappy with the response, Ms B brought her complaint to this service. The case was passed to me to decide and I didn’t think Vitality had declined the claim unfairly. So I issued a provisional decision to both parties. My provisional decision “Firstly I should clarify that in this complaint I’m reviewing what has happened up to the point Vitality issued its final response letter in May 2025. Although I’m aware Ms B ultimately received NHS treatment in September 2025 and is also unhappy with the

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outcome of her claim for an NHS cash benefit, this is not something that falls within the scope of my review. Ms B may want to raise a separate complaint with Vitality about this if she has not already done so. The relevant industry rules say an insurer must handle claims promptly and fairly and shouldn’t unreasonably reject a claim. And it should provide reasonable guidance to help make a claim with appropriate information on progress. It’s apparent from Ms B’s medical records that she had a history of knee pain and had previously undergone right knee replacement surgery. The policy moratorium says Ms B is not covered for any condition which she had, had symptoms of, treatment for or advice on, during the five years prior to taking out her policy. So it’s for me to decide whether I think it was fair for Vitality to decline the claim based on its opinion that Ms B’s knee pain was pre-existing. Having reviewed the medical evidence, I’m satisfied the right knee pain which led to Ms B needing surgery in 2025, was pre-existing in line with the policy definition. And her claim was made less than two years after the policy started. So I don’t think Vitality unfairly declined her claim. I’ll go on to explain why. The medical evidence shows Ms B presented to a GP and consultant with symptoms of right knee pain in 2023. This included a report of “severe pain” in February 2023 and pain when moving and sleeping in November 2023. And the consultant noted mild swelling of the knee on examination in December 2023. This was during the five year moratorium period prior to the policy starting. I’ve carefully considered what Ms B has said about the conclusions in the consultant’s letter in December 2023, following the x-ray of the right knee. He stated there was no suggestion of any complications with Ms B’s earlier right knee revision. So I accept Ms B was not found to need any right knee revision surgery at that time. However, the medical notes do show she was experiencing right knee pain in 2023. Ms B was referred in relation to the need for a further right knee revision operation in early 2025. And the letter from the consultant she saw in February 2025, who ultimately determined the revision was required, stated her knee was “painful and extremely swollen”. Although I’m satisfied it was not identified that Ms B required knee replacement revision surgery during the five years before the start of the policy, the medical evidence shows she had experienced symptoms of right knee pain and swelling during that time. As I’ve explained, I’m satisfied it was fair for Vitality to deem Ms B’s knee pain to be pre-existing. So to be covered for any related claims under the policy, she would have needed to have a two year period with no further consultations for the condition. However Ms B saw a consultant about her right knee pain within the first year of the policy. So it follows that I don’t find it unfair that Vitality said the claim for right knee surgery wasn’t covered. I’ve considered the argument Ms B has made about the issues with her right ankle, which may have been causing or contributing to the right knee pain. When Ms B presented with right knee pain in February 2023, it’s stated she was also experiencing right ankle pain and was awaiting an ankle replacement procedure. And the consultant said the issue with her ankle was putting an increased load on her knee. However, Ms B underwent the ankle surgery in May 2023, and was still noted to be experiencing right knee pain when she saw the GP in November 2023, and the

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consultant in December 2023. So I’m not persuaded the right knee pain Ms B reported on those later occasions can be attributed to the right ankle. I say that because the surgery had already taken place several months earlier and she was noted by the consultant to have been “recovering reasonably well” from it. She was still experiencing right knee pain at that time and the consultant noted “slightly exaggerated valgus alignment with mild swelling” on his examination of the right knee. Whilst I appreciate Ms B will likely be disappointed with my provisional outcome, I’m currently satisfied the medical evidence shows she had symptoms of right knee pain and swelling during the moratorium period. And so I don’t think Vitality unfairly declined her claim for the surgery she needed within two years of taking out the policy.” The response to my provisional decision Vitality made no comment on the provisional decision. However Ms B disagreed. In summary she said: • some of the medical evidence relates to her left leg / knee, not the right; • in the November and December 2023 medical appointments, the left knee was being discussed; • she also suffers with Lymphoedema and this has not been considered; and • her health deteriorated quickly due to Vitality’s refusal of the claim and the NHS wait times. Ms B provided a medical letter dated 18 December 2023 in which her GP referred her to a consultant due to issues with her left knee. And a copy of a letter from 2019 relating to an assessment with a Lymphoedema specialist. What I’ve decided – and why I’ve considered all the available evidence and arguments to decide what’s fair and reasonable in the circumstances of this complaint. And I've considered again my provisional findings in light of the response. Firstly, I want to reassure Ms B that I’m aware the medical evidence supplied contained comments about both of her knees. I’d focused on the relevant commentary and entries relating to her right knee when considering this complaint. Whilst the referral letter Ms B provided dated 18 December 2023 shows she was referred to a consultant due to her left knee, the medical evidence from the November 2023 GP consultation and the December 2023 consultant appointment, also comment on her previous right knee replacement and revision, and symptoms of pain with her right knee. The GP referral letter dated 8 February 2023 does not specify whether the references to the knee are about the left or the right. However the entries into Ms B’s medical record by the GP on the same date state “Problem Pain of knee region (Right)” and reference the history of the previous knee replacement. So I’m satisfied this referral was in relation to the right

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knee. In addition, the consultant’s letter following the appointment on 11 February 2023 referred to the right knee replacement revision surgery in 2014, the planned right ankle surgery and the increased load this was placing on the corresponding knee. The consultant’s letter dated 4 December 2023 commented on both knees. It specifically stated a diagnosis of “tricompartmental osteoarthritis right knee with multiple loose bodies secondary to synovial chondromatosis” and referenced the past right knee replacement and revision surgeries. The consultant wrote that Ms B had been experiencing pain, and he had examined the right knee finding it to be swollen. So, I remain persuaded that the medical evidence shows Ms B had a right knee replacement and revision surgery in the past, and was experiencing symptoms of right knee pain and sought medical advice on this, during the five year period prior to her taking out the policy. And as she required a further knee revision surgery within two years of her policy start date, I’m satisfied these circumstances were caught by the policy’s moratorium exclusion. So it follows that I still don’t think it was unfair that Vitality declined the claim. I’ve considered the September 2019 letter Ms B provided regarding a referral for Lymphoedema. But I don’t think it makes a difference to the outcome of this case. I say that because although this letter demonstrates Ms B had symptoms of another condition impacting her legs in 2019, I’ve not seen that the medical professionals referred to this as being the cause of the right knee pain and / or swelling symptoms recorded during 2023. The points Ms B raised haven’t changed my mind. So I see no reason to depart from the conclusions set out in my provisional decision and summarised above. My final decision For the reasons I’ve given, it’s my final decision that I don’t uphold this complaint. And I make no award against Vitality Health Limited. Under the rules of the Financial Ombudsman Service, I’m required to ask Ms B to accept or reject my decision before 14 April 2026. Gemma Warner Ombudsman

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