Exeter Friendly Society Limited · DRN-6165109

The complaint The estate of Mrs S has complained that Exeter Friendly Society Limited declined a claim made on a private medical insurance policy. As it is Mrs S’s son, Mr S, that is leading on the complaint, for ease, I will mostly just be referring to him in this decision. What happened Mrs S attended A&E on 24 April 2025, after which she was admitted as an inpatient. Mr S wished to have his mother transferred to a private hospital and contacted Exeter on 25 April 2025 to start arrangements for that. However, his preferred hospital was not on the hospital list that was part of Mrs S’s policy. He asked for an exception to be made, however, that request was declined. None of the hospitals on the policy’s hospital list would accept Mrs S as an inpatient. Our investigator thought that Exeter had acted reasonably, in line with the policy terms and conditions. Mr S disagrees and so the complaint has been passed to me for a 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. I’ve carefully considered the obligations placed on Exeter by the Financial Conduct Authority (FCA). Its ‘Insurance: Conduct of Business Sourcebook’ (ICOBS) includes the requirement for Exeter to handle claims promptly and fairly, and to not unreasonably decline a claim. Mr S has said that one of the main reasons the family took the policy out was because he was assured when buying it that inpatient transfers from NHS wards to a private hospital would be possible. The policy was sold by an independent financial adviser (IFA) and so Exeter played no part in what he may have been told or any misleading information he may have been given. Therefore, Mr S would need to make a complaint to the IFA if he feels that the policy was mis-sold in 2020. I appreciate what Mr S has said about the obligations of Exeter in relation to ongoing information provision. As such, it would be responsible for anything it directly told him at renewal. He’s said that the information about inpatient transfers was reconfirmed to him every year by Exeter’s customer representatives when discussing renewal. However, Exeter has confirmed that the policy auto-renewed annually, with paperwork being sent out by post. It doesn’t routinely make contact by phone, and it can’t find any record of phone calls with Mr S around renewal periods. Mr S also hasn’t provided any evidence of calls taking place. I’ll now look at what happened during the claim. Insurance policies aren’t designed to cover every eventuality or situation. An insurer will decide what risks it’s willing to cover and set these out in the terms and conditions of the

-- 1 of 3 --

policy document. The test then is whether the claim falls under one of the agreed areas of cover within the policy. So, I’ve considered the terms of the policy Mrs S held, as this forms the basis of contract between the parties. In relation to hospitals, it states: ‘If your policy includes a hospital list, you are only eligible for treatment at hospitals on your chosen list, which will be shown on your Policy Certificate. Hospital lists often change, so always check with us before arranging treatment.’ Mrs S held a Standard policy which came with a particular hospital list. The preferred hospital that Mr S wanted to transfer her to was not part of that list. Instead, it was on the list for the Extended policy, which offered a wider choice of facilities. Mr S had asked Exeter to consider allowing transfer to this hospital as an exception. This request was passed to its clinical team who maintained its position that there was no cover for this hospital. Based on the available evidence, I’m satisfied that Mrs S’s policy didn’t provide cover for the preferred hospital. It was therefore reasonable for Exeter to decline a transfer to that hospital. This left the family in a difficult situation. Mrs S was on an NHS ward and they were unhappy with the standard of care she was receiving. Mr S had rung round the hospitals that were on the Standard policy list, but none of those would agree to receive Mrs S. Part of the issue is that private medical insurance is primarily designed to support diagnostics and planned procedures. Looking at the treatment path set out in the policy terms, it generally involves a referral from a GP to a consultant, and then potentially moves on from there to some planned treatment. So, it’s not ideally suited to this more urgent type of scenario where someone is already in hospital. When Mr S first spoke to Exeter, it explained that he would need a report from the overseeing consultant detailing the reason for admission and planned diagnostics and treatment. Listening to the calls that the adviser had with the different hospitals on 28 April 2025, most of them said that Mrs S would need to see a consultant as an outpatient first before any admission for treatment. Exeter makes a range of facilities available to its policyholders under its hospital list. Not every hospital does everything, as some provide specialist services. The decision on whether a hospital is suitable, and will accept a patient, remains with the hospital itself. So, depending on the clinical need, a hospital may or may not decide that it is an appropriate venue. That applies to all sorts of treatment, not just in relation to NHS to private inpatient transfers. The hospital list simply sets out a list of possible facilities. Exeter is unable to guarantee that all the hospitals on its lists will agree to treat patients in every scenario. Mr S has said himself that, even without a consultant’s referral, another factor was that the hospitals he spoke to would not accept Mrs S in her condition and that they didn’t have the appropriate equipment to treat her. Whilst I understand that Mr S had an expectation that his mother would be able to move to a private hospital in this situation, that’s not something that Exeter had any control over as it is not responsible for clinical decisions. Following a call with Mr S’s sister on 28 April 2025, an adviser rang round a number of hospitals to see if they would accept Mrs S. He emailed afterwards to say that there was only one hospital that offered inpatient admissions. Mr S had already spoken to that hospital and knew that it would not accept his mother.

-- 2 of 3 --

As our investigator has said, what the adviser said was technically correct as that hospital does accept inpatient admissions. But only in certain circumstances and based on clinical appropriateness. The adviser was simply passing the hospital’s details on. At the time of emailing, the adviser wouldn’t have been sure that Mr S had already been in contact with that hospital. Mr S says that the lack of clarity in this email resulted in lost time. However, I’m not persuaded that’s the case because Mr S had already spoken to the hospital and knew its position that it would not accept a transfer for Mrs S. I’m aware that Mrs S subsequently passed away in June 2025. I’d like to offer my sincere condolences to Mr S and the rest of the family. In the submissions I’ve seen, it comes across very clearly how loved she was and how they wanted nothing but the best for her and to ensure that she’d be well looked after in her time of need. I therefore understand the depth of feeling involved in this complaint and how let down they feel that their expectations around what the policy would provide were not met. So, I’m very sorry to disappoint Mr S, but I’m unable to conclude that Exeter did anything significantly wrong. It was reasonable for it to decline cover for the preferred hospital, in line with the policy terms and conditions. And the hospitals on the list not accepting the transfer- in was outside of its control. It follows that I do not uphold the complaint. My final decision For the reasons set out above, I do not uphold the complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask the estate of Mrs S to accept or reject my decision before 22 April 2026. Carole Clark Ombudsman

-- 3 of 3 --