Private medical insurance disputes can involve both medical evidence and contract wording. A treatment being clinically appropriate does not automatically mean it is insured, but an insurer should apply eligibility, pre-authorisation and pre-existing-condition rules fairly.
Insurance disputes are rarely decided by one sentence in the policy. The wording, what the insurer asked, what happened, the evidence and the reason given for the decision all matter. Keep those questions separate so the complaint stays testable.
Key points
- Check whether the cover is individual, employer/group, cash-plan, dental or another medical policy; rights and policyholder status can differ.
- Pre-existing-condition disputes depend on definitions, underwriting method and medical chronology.
- Some policies require pre-authorisation or treatment through approved providers; ask whether failure to follow the process genuinely justifies the refusal.
- For employer group cover, the employee may be a beneficiary rather than the policyholder, but FOS can still be relevant depending on the complaint.
Diagnosis
First: what exactly has happened?
Start by identifying the actual dispute. Similar-looking insurance complaints can turn on very different rules.
| What happened? | What to check first |
|---|---|
| Treatment is refused as pre-existing | Compare the definition with symptoms/diagnosis/treatment before cover. |
| The insurer says treatment was not pre-authorised | Check the process, urgency and whether the policy makes authorisation a condition of payment. |
| The insurer stops funding ongoing treatment | Ask whether a monetary/time limit or clinical eligibility criterion has been reached. |
| The consultant/hospital is outside the network | Check provider restrictions and what information was given before treatment. |
| The employer arranged the policy | Identify the policyholder, beneficiary rights and who made the disputed decision. |
| The policy was sold as broader than it is | Separate mis-selling from the claim interpretation and preserve sales evidence. |
Pre-existing medical conditions
Ask the insurer to identify the policy definition and the medical evidence showing the condition falls within it. Symptoms can matter even before formal diagnosis, depending on the wording, but a later diagnosis does not automatically prove an earlier excluded condition.
Underwriting method matters
Moratorium and fully medically underwritten policies treat prior conditions differently. Identify how the policy was underwritten and what information was requested when the cover began.
Pre-authorisation
Many policies require the consumer to contact the insurer before treatment. If a claim is refused for lack of authorisation, ask whether the term is absolute, whether the treatment would otherwise have been eligible and whether urgent circumstances made prior contact impracticable.
Approved hospitals and fee schedules
The insurer may restrict hospitals, consultants or fee levels. If the consumer was told to use a particular provider or received approval, preserve that communication. Unexpected shortfalls can turn on what was authorised and how clearly limits were explained.
Ongoing or chronic treatment
Private medical policies often distinguish acute treatment from chronic conditions. Ask for the definition, clinical evidence and the point at which the insurer says treatment ceased to meet the policy criteria.
Group/employer policies
The employer may own the policy while employees are beneficiaries. Complaint routes can be more complex, particularly where the dispute concerns employer administration rather than the insurer's claim decision. Identify who made the decision you are challenging.
What to say next
Ask the insurer to identify the eligibility clause, medical evidence and any authorisation/network rule relied on. Obtain a focused clinician letter where the dispute is medical, addressing the insurer's actual criterion rather than simply stating that treatment is beneficial.
Who is responsible?
The insurer decides benefit eligibility, but treatment providers make clinical decisions. An employer may administer a group scheme and an adviser/broker may have sold the policy. Identify whether you are disputing the insurer's cover decision, the provider's treatment, employer administration or sales advice.
FOS can consider many regulated medical-insurance complaints, but it is not a clinical negligence forum for the quality of medical treatment itself.
What remedy is realistic?
If cover was wrongly refused, the insurer may need to fund or reimburse eligible treatment within policy limits. If the consumer paid privately because of an incorrect refusal, keep invoices and evidence that the treatment was otherwise within cover.
Where the policy was mis-sold, the remedy can involve cancelling the policy, refunding premiums or compensating the consumer for the position they would have been in with suitable cover, depending on the facts.
Important exceptions and edge cases
Some policies use moratorium underwriting, where pre-existing conditions can become eligible after a symptom/treatment-free period; others use full medical underwriting. The answer can change completely depending on the underwriting basis.
Emergency treatment, chronic conditions, experimental treatment, mental-health benefits and overseas treatment can have specialist limits. Use the product-specific wording rather than general assumptions about what private medical insurance should cover.
Common insurer responses - and what they do not necessarily prove
| The insurer says | What to test |
|---|---|
| "The condition is pre-existing." | Ask for the definition and medical chronology showing why it falls within the exclusion. |
| "The treatment was not authorised." | Check whether authorisation was required, whether it would otherwise have been covered and what the insurer told you. |
| "Your consultant charges above our limit." | Ask what fee limit was communicated and whether an approved alternative was realistically available. |
| "Your employer is the policyholder." | That can affect administration, but identify whether the complaint is about the insurer's regulated decision or the employer's actions. |
Evidence worth keeping
Build the file around the issue the insurer actually has to decide. Preserve documents from the time of the claim rather than relying on memory later.
What to do
A practical next-step plan
- Identify the policy type and underwriting basis.
- Ask for the exact eligibility/exclusion/authorisation reason.
- Obtain focused medical evidence on the disputed criterion.
- Separate insurer decisions from employer/group administration.
- Complain formally and refer an eligible unresolved dispute to FOS.
What happens after you make a formal complaint?
The insurer or other regulated firm should acknowledge and investigate the complaint under the FCA complaint rules. For most ordinary insurance complaints it should send the required written response within eight weeks. Keep the complaint separate from day-to-day claim chasing: the claim can continue progressing while the complaint tests the decision or handling.
If you receive a final response and remain dissatisfied, check Financial Ombudsman eligibility immediately. FOS normally requires referral within six months of the date on a valid final response. Continuing to argue with the insurer does not safely stop that external clock, so diary it even if the firm says it is willing to look again.
Official sources
Check the current source material.
Insurance rules, policy wording and Financial Ombudsman approaches can change. Check the live source and the policy wording for the relevant policy year before relying on a formal deadline, exclusion or remedy.