Leila’s insurer declined her claim for breast reduction surgery she made through her private medical insurance policy. The insurer said cosmetic treatments such as Leila’s surgery weren’t covered under the policy terms.
What happened
Leila’s insurer declined her claim for breast reduction surgery on the basis that it was a cosmetic treatment. The policy terms didn’t include a specific exclusion for the removal of healthy tissue.
Leila disagreed. She felt her insurer didn’t take everything into account, and if it did – it would’ve payed her claim. So she complained, unhappy with the response, Leila referred her complaint to us.
What we said
We checked Leila’s medical records which showed that she’d started experiencing acute back pain. We checked this with her consultant. He confirmed all other options had been ruled out and that surgery was the only way to relieve her symptoms, which were severe. He said there was a direct link between the back pain and the need for the breast reduction surgery.
The consultant was a recognised specialist in this field. So, when we compared it to the insurer’s medical report, we were more persuaded by what her treating consultant had to say.
We explained to the insurer that we didn’t think it was fair for them to rely on the exclusion for cosmetic surgery. The medical evidence confirmed Leila’s surgery was intended to relieve the symptoms of her back pain. This meant there was a medical need for the surgery – it wasn’t a cosmetic treatment. So we said the insurer should pay Leila’s claim.