Vitality Health Limited · DRN-6094606

The complaint Mr G is unhappy with Vitality Health Limited’s decision to decline his claim for his son’s treatment. Although this complaint relates to Mr G’s son, I’ll refer to Mr G throughout for simplicity. What happened Mr G has private medical cover for him and his family with Vitality. Mr G requested a referral to a specialist for his son’s ingrown toenail. Mr G said he used the contact information provided by Vitality and arranged to see a specialist. Following the treatment, Mr G submitted his invoices for payment, only to be told Vitality wouldn’t reimburse his costs. Mr G would like the insurer to pay the claim. Vitality said when it initially spoke to Mr G, it authorised two sessions with the specialist but said any treatment would need to be discussed with it first. It said Mr G didn’t see any of the specialist’s it’d provided and that he went ahead with treatment without authorisation. It maintained its decision to decline his claim for those reasons. Our investigator didn’t uphold this complaint. She said because Mr G didn’t see a specialist within Vitality’s approved network, it could reasonably decline his claim. She also said Mr G didn’t call Vitality prior to receiving treatment and that this was something the insurer asked him to do during the referral phone call. Mr G, unhappy with that, asked for an ombudsman to review his complaint. He said, in summary, the specialist’s contact information provided by Vitality was incorrect. He used the telephone number for one of the specialists on the list to arrange the appointment and that he wasn’t to know the clinic had arranged for him to see a specialist outside of Vitality’s network. And so, it’s now for me to make a final decision. 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. Having done so, I’ve decided not to uphold it and for broadly similar reasons to those given by our investigator. It’s clear an error occurred and that Mr G took his son to see a specialist outside of Vitality’s approved network, but I’m satisfied this wasn’t because of any mistake made by the insurer. I’ll explain why. The relevant rule that applies in this case comes from the Insurance Conduct of Business Sourcebook (ICOBS) and says Vitality must assess claims promptly and fairly and must not reject a claim unreasonably. I’ve considered this and other relevant industry guidance whilst assessing Mr G’s complaint. Although I may not respond to every point Mr G has raised, I want to reassure him I’ve considered everything he’s said. The informal nature of this service enables me to do that so

-- 1 of 3 --

I can resolve complaints with minimal formality. The policy terms say: “When you need treatment covered by the plan, you will be able to choose the medical professional who treats you, and where the treatment takes place. The choices available to you will depend on the options chosen by the planholder” And: “Consultant Select We recognise the vast majority of consultants working in private practice in the UK. To help you make an appropriate choice, we assess all consultants for robust clinical practice, excellent treatment outcomes and how efficiently they deliver healthcare. Should you need to see a consultant, we provide you with a choice of recognised consultants to choose from who score highly on these measures, and that are appropriate for your condition and where you live.” And: “We will not pay for the following treatments: … any treatment provided by, or undertaken whilst under the care of, a consultant, therapist or complementary medicine practitioner or other clinician who is not recognised by us for the treatment being provided” And: “It is very important for you to contact use before having any treatment, so we can ensure the treatment, medical practitioner and hospital are covered on your plan” Mr G was provided with a list of three specialists he could take his son to see about his ingrown toenail. Mr G said he called the contact number provided and arranged to see a specialist. The issue here is that Mr G saw a different specialist to the one Vitality provided. Mr G explained he told the clinic he was a Vitality policy holder and so he assumed he’d be referred to a specialist recognised by his insurer but that didn’t happen. I can’t say with any certainty who’s responsible for the confusion, but I’m satisfied the mistake wasn’t caused by Vitality. The evidence shows the insurer provided the names of three approved specialists and their contact information, which is what I’d expect it to do for eligible treatment under the policy. Mr G said the treatment for his son’s condition was covered by the policy and so Vitality should pay those costs. But I don’t think that’s fair in the circumstances. I should say eligible treatment isn’t the only consideration for the insurer as it must also be carried out by a specialist within its approved network. Mr G’s claim doesn’t satisfy that criteria because it was carried out by an unrecognised specialist. And so, it can fairly decline the claim for those reasons. Vitality also said it didn’t give Mr G authorisation for any treatment of the condition. It explained the authorisation was to see a specialist and any proposed treatment would need to be authorised separately before going ahead. I’ve listened to a call between Mr G and Vitality, and I’m satisfied this was clearly explained. Had Mr G called the insurer to authorise the treatment, it would have been able to provide further information about the appointments he’d already attended and made sure one of its recognised specialists completed the treatment. Mr G argued some of the specialist’s contact information Vitality initially provided was incorrect. Vitality apologised for that and explained it’s the clinician’s responsibility to ensure their contact information is up to date. It said had Mr G notified it of that at the time it could have sourced other specialists. I’ve not seen any evidence that happened and so I don’t think there’s anything more I could reasonably expect the insurer to do here.

-- 2 of 3 --

My final decision For the reasons I’ve explained, I don’t uphold this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr G to accept or reject my decision before 23 April 2026. Scott Slade Ombudsman

-- 3 of 3 --