DRN-6316935

The complaint The estate of Miss C complains Vitality Health Limited (Vitality) declined the claim Miss C was looking to make under a private medical insurance policy. Mrs C has been leading in this complaint on behalf of the late Miss C’s estate and so for ease, I’ve referred to her throughout. What happened Miss C was covered under a group private medical insurance policy through her former employer. The policy was underwritten on a moratorium basis with a start date of 9 November 2022. As she was leaving her employment her policy end date was recorded as 6 August 2024. In June 2024 Miss C contacted Vitality as she was looking to claim for a psychiatrist appointment she had attended. Following discussion Vitality said it would be unable to provide cover as Miss C had said she had seen a therapist following feeling low prior to the policy start date. On 2 August 2024 Miss C contacted Vitality again as she was looking to check herself into a mental health clinic and wanted this covered. Vitality maintained its position that this wouldn’t be covered based on the reasons it had set out previously. On 5 August 2024 Miss C and Mrs C spoke to Vitality contesting its decision to decline cover. Vitality didn’t change its mind. On 6 August 2024 Miss C’s treating psychiatrist called Vitality asking why the claim had been declined. They also said they didn’t believe the reason for Miss C’s current treatment was pre-existing. Vitality told Miss C’s psychiatrist the policy cover had ended that day. An inpatient admission request was also submitted but this wasn’t agreed as Vitality said the claim had been declined and the policy had ended. On the evening of 6 August 2024 Miss C sadly took her own life. Mrs C raised a complaint with Vitality about the way it had handled Miss C’s claim and its decision to decline her claim for treatment. On 12 November 2024 Vitality issued Mrs C with a final response to the complaint. It said it didn’t think its decision to decline cover was incorrect based on the information it had at that time. It did acknowledge errors in its service which included not logging a complaint when it should have done, not calling Miss C back following a dropped call, and an incorrect call transfer. Mrs C referred the complaint to this Service. Our Investigator looked into things. She said she didn’t think Vitality had acted fairly when it declined Miss C’s claim. She thought Vitality should accept the claim for treatment and pay 8% per year simple interest on this amount. She also thought it should pay £350 compensation for the distress and inconvenience caused to Miss C. Vitality didn’t agree with our Investigator. However, it said without any admission of liability, it would agree to reimburse the cost of the psychiatrist appointment from June 2024 and admission from August 2024. It also said it would pay the estate £350 as a gesture of goodwill.

-- 1 of 6 --

Mrs C didn’t accept this. She provided a detailed response but in summary she said: • Vitality had incorrectly applied the moratorium clause which caused Miss C additional anxiety and uncertainty at a time when she should have been focusing on treatment and recovery. • Vitality maintained its incorrect decision over a significant period of time, requiring considerable effort to challenge. • She would like an ombudsman to consider whether the £350 compensation appropriately reflects the detriment caused by Vitality’s actions. • There was a further psychiatrist appointment from July 2024 which hadn’t been considered. • This case raised broader concerns regarding the handling of urgent mental health claims. I issued a provisional decision about this complaint and I said: ‘I want to acknowledge I’ve summarised this complaint in less detail than Mrs C has presented it in. I’ve not commented on every point she has made. Instead, I’ve focused on what I consider to be the key points I need to think about. I mean no discourtesy by this, but it simply reflects the informal nature of this Service. I want to assure Mrs C and Vitality I’ve read and considered everything that’s been provided. I also want to be clear about what I’ve considered as part of this decision. I appreciate Mrs C has said she has wider regulatory concerns following her complaint. However, the role of this Service isn’t that of a regulator. So, I can’t impose fines or penalties on businesses for poor claim handling or service, nor can I require it to change its processes. Instead, I’ve considered whether Vitality has made errors and if so, how this impacted Miss C and what it needs to do to put things right. I’m aware Mrs C has also highlighted the distress and inconvenience the estate has been caused by Vitality’s actions. This Service are only able to make awards for distress and inconvenience to ‘eligible complainants’, which in this instance would be Miss C. Whilst Miss C’s estate is able to bring a complaint to this Service on behalf if Miss C, it isn’t an eligible complainant in its own right. So, I’m unable to make any awards of compensation for distress and inconvenience caused to the estate as they aren’t party to the contract of insurance. The relevant rules and industry guidelines explain Vitality should handle claims fairly, and shouldn’t unreasonably reject them. Vitality has agreed to reimburse the cost of Miss C’s psychiatrist appointment in June 2024 and admission in August 2024. It has now also agreed to reimburse the cost of the further psychiatrist appointment Mrs C said Miss C had in July 2024. This will mean the cost of Miss C’s treatment will be reimbursed. However, the crux of Mrs C’s complaint is that the claim was unreasonably rejected, causing Miss C distress and inconvenience. The terms of Miss C’s policy explained Vitality won’t pay claims for the treatment of any medical condition or related condition, which in the five years before the policy started Miss C had received treatment for, had symptoms of, or asked advice on. This is unless Miss C had a two-year period where she hadn’t consulted anyone for

-- 2 of 6 --

treatment or advice, or taken medication for that condition following the policy start date. The policy terms explained a related condition is any symptom, disease, illness or injury which reasonable medical opinion considers to be associated with another symptom disease, illness or injury. I’ve listened to the call Miss C had with Vitality in June 2024. During this call she said she had a psychiatrist appointment for work-related stress but had been diagnosed with depression and anxiety. She said she had seen a therapist before but wouldn’t consider this to be mental health treatment and that she had seen him because she was quite low. She also said this was in 2019 or 2020, but she reiterated that the two things were completely different. Based on the information Miss C provided during this call, and the terms of her policy, I don’t think it was unreasonable Vitality declined to cover her treatment at this stage. Miss C’s policy start date was November 2022. Whilst I acknowledge Miss C had said what she had seen a therapist for in 2019 or 2020 was completely different to what she was experiencing in 2024, she had said she had seen a therapist following feeling low. I don’t think it was unreasonable for Vitality to conclude she had experienced symptoms of, and received treatment or advice for, the condition or a related condition she was looking to claim for, in the five years prior to her policy start date. And the policy hadn’t been in force for two years by this stage. I appreciate there was the option for Vitality to allow Miss C and her treatment provider to complete a claim form so they could consider the claim in more detail. However, given the information Miss C provided during this call from June 2024, I don’t think it was unreasonable Vitality didn’t request this at the time. On 5 August 2024 Mrs C had several phone conversations with Vitality. During these conversations she said the appointment was in 2018 and it wasn’t for anxiety and depression but was following a relationship break-up. She also said Miss C had seen a life coach not a therapist. I think based on these conversations Vitality could have sought further information from Miss C’s treatment providers so it could appropriately re-consider her claim. I think the information provided by Mrs C suggested this wasn’t straightforward and it was possible there may be a valid claim. Additionally, I don’t think it was reasonable Vitality didn’t explore this further when Miss C’s psychiatrist told it they didn’t believe her current treatment was pre-existing and when the inpatient admission form had been received. The information on the inpatient admission form showed Miss C’s condition was a complex one, and a medical professional had said they didn’t think it was linked to any previous treatment. I acknowledge Miss C’s policy was due to end on 6 August 2024, but Vitality was aware Miss C had received treatment in June 2024 and was admitted to a mental health clinic prior to the policy end date. So, even if it couldn’t provide cover for treatment beyond the end date of the policy, it was aware Miss C had received treatment prior to this which she was looking to claim for. Whilst I think Vitality could have sought further information, I don’t think it would have been able to request, receive and review this prior to Miss C’s sad passing. I think it would have needed to request information from Miss C’s GP, and the therapist/life

-- 3 of 6 --

coach she had seen previously, all of which would have taken some time. I’m also unable to say what the outcome of this would have been and whether this would have ultimately meant Miss C’s claim would have been accepted. As I’ve said I think further information would be required before this could be reviewed further. Given Vitality has now agreed to cover the cost of the treatment Miss C received, and the circumstances of this case, I don’t think it would be appropriate to require Vitality to request this information now. I think Miss C would have experienced distress being told her claim had been declined. And I can appreciate this could have been lessened by Vitality agreeing to re-consider her claim following receipt of medical evidence. However, I’ve also taken into consideration that she wouldn’t have had any certainty her claim would be paid. Additionally, this was clearly a very complex medical situation and so I don’t think it would be appropriate for me to conclude circumstances would have been different had Vitality agreed to re-consider things. Taking all of this into consideration, I think Vitality paying Miss C’s estate £350 is reasonable in the circumstances. I think this fairly takes into consideration the distress to Miss C caused by Vitality’s errors, including the failed callbacks and failure to log a complaint. And I think it’s agreement to reimburse Miss C’s treatment costs, alongside 8% interest leads to a fair outcome in all of the circumstances.’ Vitality didn’t provide me with new evidence or comments to consider. Mrs C provided a detailed response but in summary she said: • The handler Miss C spoke to in June 2024 asked a leading question around previous mental health treatment. The handler also alters Miss C’s comment that she visited a therapist after feeling quite low, to her suffering from ‘low mood’ which has different connotations. • The conversation Miss C had with the handler in June 2024 shouldn’t have automatically led to the handler concluding she had experienced symptoms of or received treatment for a related condition. • Had the handler alerted Miss C properly to the possibility of completing a claim form she would have been able to explain that she had met a life coach, not a therapist, and there was no referral from a GP or medication. She would have also been able to involve her treatment provider which Mrs C believes would have led to cover being agreed. • Had the financial worry been lifted or at the very least, Miss C been aware reassessment was being taken in August 2024, who knows what the effect may have been. • She acknowledges this service isn’t a regulator, but her goal remains to bring about a procedural change for all mental health claims made to insurance companies to give members the options to have claim decisions referred to a mental health trained professional for a second opinion. • She doesn’t consider Miss C’s claim was handled fairly and it was unreasonably rejected.

-- 4 of 6 --

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. It’s clear Mrs C has spent a great deal of time and care when responding to the provisional decision. So, I want to reiterate that whilst I’ve not highlighted every point she has raised, I have read and considered everything she has provided. I acknowledge during the phone call with Vitality in June 2024 Miss C didn’t say she had suffered from low mood, rather she said she had seen a therapist after feeling low. However, I don’t think this means Vitality acted unreasonably when it told Miss C it couldn’t accept her claim. Whilst Miss C had said what she had seen the therapist for previously was different, she had told Vitality she had been feeling low and that she had seen a therapist as a result. In these circumstances I don’t think it was unreasonable for Vitality to conclude Miss C had suffered symptoms of, or received treatment for, the condition or related condition she was now looking to claim for. And based on the information provided, I don’t think it was unreasonable it didn’t ask Miss C to complete a claim form or provide further information about her treatment. As I said in the provisional decision, I think Vitality should have sought further information in August 2024 following discussions with Mrs C and Miss C’s treatment provider. However, given the complexities of Miss C’s condition and external factors involved, I don’t think it would be appropriate for me to conclude that circumstances would have been different even had Vitality agreed to consider the claim further. I acknowledge Mrs C’s desire to bring about changes in how mental health claims are considered by insurance providers moving forward. But as this Service isn’t a regulator, I can’t require Vitality change the way it handles its claims or the processes it has in place. Having taken into consideration everything both parties have provided, I’ve reached the same outcome to the one I reached in my provisional decision for the same reasons as set out previously. I know this will be disappointing for Mrs C, but I hope I’ve explained clearly the reasons for reaching the decision I have done, and that there is a small comfort in knowing the complaint has been considered by an impartial party. My final decision For the reasons I’ve outlined above, I uphold the estate of Miss C’s complaint about Vitality Health Limited. I require it to: • Reimburse the estate of Miss C the cost of treatment for the June 2024 and July 2024 psychiatrist appointments, and her admission to the mental health clinic. • *Pay 8% per year simple interest on these amounts calculated from the date the expenses were incurred to the date they are reimbursed. • Pay the estate of Miss C £350 compensation. *If Vitality Health Limited considers that it’s required by HM Revenue & Customs to deduct income tax from that interest, it should tell the estate of Miss C how much it’s taken off. It should also give the estate of Miss C a tax deduction certificate if they ask for one, so they can reclaim the tax from HM Revenue & Customs if appropriate.

-- 5 of 6 --

Under the rules of the Financial Ombudsman Service, I’m required to ask the estate of Miss C to accept or reject my decision before 26 May 2026. Andrew Clarke Ombudsman

-- 6 of 6 --