Vitality Health Limited · DRN-6090274

The complaint Mrs M complains about the service she received from Vitality Health Limited when she made a claim on a personal private medical insurance policy. What happened The background to this complaint is well-known to both parties. So I’ve simply set out a summary of the main events. Mrs M took out a personal private medical insurance policy in 2018. In November 2024, she was referred for a consultation with a neurologist due to pins and needles and leg numbness. So she made a claim on her policy. Vitality provided Mrs M with the details of three neurologists so that she could arrange an appointment. However, Mrs M wasn’t able to book an appointment with any of those consultants. So in mid-December 2024, Mrs M complained to Vitality because she was unhappy with the service she’d received. It provided her with the details of more consultants. As Mrs M still wasn’t able to arrange a timely appointment, she contacted Vitality again on 17 and 18 December 2024. On 18 December 2024, Vitality told Mrs M that it’d booked her an appointment on 13 January 2025. However, Mrs M explained that she was attending an important occasion on that day, so wouldn’t be able to attend. Vitality got in touch with the relevant hospital to cancel the appointment. However, due to apparent miscommunication during the call, the appointment remained in place. Following the call, Mrs M’s claim was passed to Vitality’s concierge service. As the appointment of 13 January 2025 hadn’t been cancelled, Mrs M received an appointment reminder from the hospital shortly before the planned appointment date and Mrs M had to cancel the appointment on the day. Having looked into Mrs M’s complaint, Vitality accepted that she’d struggled to find a suitable consultant and that she’d chased things up with it several times. It also accepted it could have passed Mrs M details to its concierge service sooner to try and help her. But it also said that while it would provide customers with details of three consultants, it was ultimately a policyholder’s responsibility to book a consultant and it had no control over a consultant’s availability. It offered Mrs M £100 compensation for the difficulties she’d experienced. Mrs M remained unhappy with Vitality’s position. She cancelled her policy with it and took out new cover with a different insurer. She was able to secure a neurology appointment very quickly. Following a diagnosis of a disc prolapse, Mrs M underwent spinal surgery to treat her condition. She didn’t agree the compensation Vitality had offered was fair. She felt compensation in line with the premiums she’d paid for the policy of around £14,000 would be more reasonable. She asked us to look into her complaint. Ultimately, our investigator thought Vitality should pay Mrs M total compensation of £200.

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She thought the policy terms made it clear that Vitality wasn’t responsible for the availability of consultants. And she considered Vitality had taken steps to try and help Mrs M. However, she thought Vitality had failed to cancel the appointment it had booked for Mrs M and she was satisfied that receiving a reminder message had caused Mrs M additional upset and inconvenience. So she didn’t think the £100 Vitality had already offered went far enough. Neither Mrs M nor Vitality agreed with the investigator’s view and so the complaint’s been passed to me to decide. 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, whilst I’m very sorry to disappoint Mrs M, I’ve decided the fair outcome to this complaint is for Vitality to pay her total compensation of £200 and I’ll explain why. First, I’d like to say how sorry I was to read about Mrs M’s symptoms, eventual diagnosis and surgery. It’s clear this has been a very worrying and upsetting time for her and her family. I’d also like to reassure both parties that while I’ve summarised the background to this complaint and their submissions to us, I’ve carefully considered all that’s been said and sent. However, I haven’t addressed each point that’s been raised and I’m not required to under our rules. Instead, I’ve focused on what I believe to be the key issues. I’ve taken the relevant regulator’s rules and principles – including the Consumer Duty - into account, amongst other relevant considerations, such as the policy terms and the available evidence, in deciding whether I think Vitality treated Mrs M fairly. The policy terms I’ve first considered the policy terms and conditions, as these form the basis of Mrs M’s contract with Vitality. Page 23 sets out ‘Your hospital and treatment options’. It says: ‘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.’ Page 23 adds: ‘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 page 35 states: ‘We make no representations or recommendations to you or any of your insured dependants regarding the availability and standard of any treatment or services offered or provided by any provider. We will not be held liable to you or any insured dependant for any loss, harm or damage of any description resulting from lack of availability or from a defect in the quality of any treatment or service offered or provided by such provider.’ I think the policy terms make it clear that Vitality isn’t responsible for the availability of the consultants on its ‘approved’ lists. I also think the contract makes it clear that Vitality isn’t responsible for booking appointments on a policyholder’s behalf. Instead, it provides policyholders with the details of potentially suitable consultants so that they can decide which doctor is right for them. In my experience, most private medical insurers operate in a similar way.

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On that basis, I don’t think I could fairly or reasonably find that Vitality ought to have booked Mrs M appointments or looked into consultant availability from the outset. Instead, I’m satisfied that it appropriately provided Mrs M with details of neurologists who might be able to assist her, so that she could get in touch with them directly. Customer service It’s clear that Mrs M did have a great deal of difficulty in arranging a neurologist appointment, at a time when she was suffering from worrying symptoms. So I can entirely understand how important it was to her to be seen by a specialist. She was trying to find an appointment for over five weeks, which I don’t doubt caused Mrs M a great deal of frustration. It’s also clear that she made a number of calls to Vitality to explain the situation and to ask for help. Having listened to those calls, I think that for the most part, Vitality treated Mrs M with empathy and tried to support her by providing her with details of other consultants who might be able to help and also by ultimately calling the hospitals directly. With that said, Vitality accepts that given the difficulties Mrs M was experiencing, it could and should have passed her details to its concierge team sooner than it did. This may have reduced the number of calls Mrs M needed to make and it could have potentially assisted her by booking an appointment directly. However, when Vitality’s call handler had tried to make direct calls to try and arrange neurology appointments prior to the concierge handover, they hadn’t been able to book any appointments sooner than mid-January. So it isn’t clear that Mrs M could have seen a consultant any sooner even if the concierge handover had happened earlier. Having listened to the calls, I appreciate Mrs M clearly told Vitality’s call handler that she couldn’t attend the appointment that they’d booked for her on 13 January 2025 because she was already attending an important occasion. And she’d understood the appointment would be cancelled. However, she received an appointment reminder from the hospital and had to cancel the appointment on the date it was supposed to happen. Understandably, given the nature of the event Mrs M was attending and the stress of worrying whether she’d need to pay a cancellation fee caused her additional, unnecessary upset. Vitality provided us with a copy of a call between its call handler and the private hospital and the call handler did explain the situation to the hospital. An alternative appointment date and time were discussed. But, at the end of the call, the hospital stated that it would leave things as they were. In my view, that clearly indicated that the appointment of 13 January 2025 would remain in place. Vitality’s call handler didn’t reiterate that the original appointment would still need to be cancelled, as I think they ought to have done. And it seems to me that this was the reason the appointment remained booked. So I think Mrs M’s worry and upset on this point could have been avoided. In the round then, I find there were service failings on Vitality’s part which caused Mrs M avoidable, material distress and inconvenience. Fair compensation So I now need to explore what I think fair compensation should be. I appreciate Mrs M feels that the compensation our investigator recommended doesn’t go far enough and I’ve considered that point carefully. I understand she feels that some refund of premium is due, as she wasn’t able to make use of her policy in the way she wanted to and she’s also questioned whether her ultimate diagnosis would have been as serious had she been seen sooner. I don’t think it would be fair or reasonable for me to award the level of compensation Mrs M

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is seeking. I accept that Mrs M wasn’t able to make use of the policy in the way she’d hoped to but as I’ve explained, I’m satisfied Vitality met its contractual obligations and it did try and provide her with support to arrange a suitable appointment. Vitality was covering the risk of Mrs M making a claim throughout the life of policy and it did authorise consultations. The evidence indicates it would have paid for the costs of Mrs M’s appointments and there’s nothing to suggest it wouldn’t have covered any treatment she needed. So I don’t think I could fairly or proportionately award any refund of premiums. Nor have I seen any persuasive evidence that any delay in Mrs M seeing a neurologist caused a deterioration in her condition. And while I understand she was able to promptly see a neurologist once she’d taken out new cover elsewhere, that doesn’t mean Vitality did anything wrong. It’s possible that the other insurer used consultants on different lists or at different hospitals who simply had more availability. In the round, I think £200 is a fair, reasonable and proportionate award which reflects the impact on Mrs M of the mistakes I think Vitality made – its delay in passing Mrs M’s claim to its concierge service and its failure to properly cancel her appointment on 13 January 2025. I’m satisfied too that this is in line with our published approach to awards for distress and inconvenience. So, despite my natural sympathy with Mrs M’s position, I’m now directing Vitality to pay her total compensation of £200 (inclusive of the £100 it’s already offered). My final decision For the reasons I’ve given above, my final decision is that I partly uphold this complaint and I direct Vitality Health Limited to pay Mrs M total compensation of £200 (inclusive of the £100 it’s already offered). Vitality must pay the compensation within 28 days of the date on which we tell it Mrs M accepts my final decision. If it pays later than this, it must also pay interest on the compensation from the deadline date for settlement to the date of payment at 8% a year. Under the rules of the Financial Ombudsman Service, I’m required to ask Mrs M to accept or reject my decision before 2 April 2026. Lisa Barham Ombudsman

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