Pre-existing condition
The insurer says symptoms, treatment or a diagnosis existed before cover began or within a moratorium or waiting period.
Private medical & dental insurance disputes
Private Medical or Dental Insurance Claim Refused?
Private medical and dental claims can become disputed when an insurer says treatment is not covered, a condition is pre-existing or chronic, pre-authorisation was not obtained, or only part of the treatment cost is payable. We review the policy wording, medical evidence and insurer's reasoning before identifying the strongest realistic next step.
✓Free Initial Review
✓Policy & Medical Evidence Review
✓FOS Complaint Support
✓Litigation & Barrister Routes
Why medical and dental claims become disputed
The Insurer May Accept the Need for Treatment but Still Say the Policy Will Not Pay
These disputes often turn on a narrow policy term: whether the condition existed before cover, whether treatment is acute or chronic, whether it is medically necessary, or whether the insurer's authorisation rules were followed.
Chronic condition exclusion
Further treatment is refused because the insurer says the condition is ongoing, long-term or primarily aimed at controlling symptoms rather than curing an acute episode.
Treatment said not to be eligible
The insurer argues the proposed treatment is preventative, cosmetic, experimental, unproven or outside the definition of eligible treatment.
Pre-authorisation problem
Treatment has already taken place but the insurer says approval should have been obtained first or that the chosen consultant, dentist or facility was outside its permitted network.
Only part of the treatment is paid
The insurer applies a benefit limit, fee schedule, excess, contribution, provider cap or another restriction which leaves a substantial shortfall.
Funding stopped during treatment
The insurer initially authorised or funded treatment but later says continuing treatment no longer meets the policy's requirements.
What IDS reviews
The Medical Evidence Has to Be Compared With the Actual Policy Wording
A doctor's recommendation that treatment is appropriate can be important, but the insurance question is whether the treatment falls within the policy. We focus on the specific point where the clinical evidence and insurer's interpretation diverge.
The insured treatment and exclusions
We identify the benefit being claimed, the definitions that apply and any exclusion or restriction the insurer says prevents payment.
The medical or dental evidence
Consultant, GP, dentist and specialist evidence is compared with the insurer's stated reason for refusing, restricting or ending cover.
Pre-existing and chronic-condition reasoning
We examine the chronology of symptoms and treatment, relevant definitions and whether the insurer has properly connected earlier medical history with the present claim.
Authorisation and payment limits
We review whether approval requirements, provider restrictions, benefit caps or fee schedules were clearly set out and correctly applied to the claim.
Financial Ombudsman approach
What Does the Financial Ombudsman Look At?
The Financial Ombudsman says it sees private medical and dental complaints where insurers take too long to pay, refuse part of the treatment, stop paying for treatment, or rely on pre-existing-condition wording. It also considers disputes about how the policy was sold or explained.
When reviewing a claim complaint, the Ombudsman looks at the policy terms and conditions, the available evidence and whether the insurer handled the claim promptly and fairly. An insurer should not reject a claim unreasonably simply because treatment falls near the boundary of a policy definition.
Read the Financial Ombudsman's current guidance on private medical and dental insurance.
How we approach the dispute
From Treatment Refusal to a Focused Challenge
The goal is to establish exactly which term the insurer is relying upon, whether the medical evidence supports that interpretation and what proportionate route may be available to challenge it.
Identify the coverage issue
We isolate the treatment, condition, authorisation rule, exclusion or limit that the insurer says prevents or reduces payment.
Test the insurer's reasoning
The policy wording is compared with the clinical evidence, chronology and any explanation supplied by the treating professional or insurer.
Escalate where appropriate
The next stage may involve further evidence, a structured complaint, FOS where eligible, or more formal dispute support in suitable higher-value cases.
What to send us
Start With the Decision and the Treatment Evidence
You do not need to assemble every medical record before contacting us. Send what you have and we can identify which additional documents may matter.
The insurer's refusal or partial-payment decision
Policy schedule and private medical or dental wording
Consultant, dentist or treating specialist reports
Pre-authorisation correspondence or treatment approvals
Relevant medical history or chronology of symptoms
Invoices, benefit calculations and complaint correspondence
When the dispute needs to go further
Treatment Disputes Can Become Urgent When Funding Has Stopped
Where treatment is ongoing, delay or refusal can create immediate practical and financial consequences. Depending on eligibility, value, evidence and legal issues, IDS can help organise the dispute for escalation and, where appropriate, more formal legal or barrister input.
Focused insurer challenge or formal complaint
Financial Ombudsman support where eligible
Medical and policy evidence preparation
Litigation or specialist barrister support where appropriate
Common questions
Private Medical & Dental Insurance Dispute FAQs
Can an insurer refuse treatment because it says my condition is pre-existing?
Potentially, depending on the policy and how pre-existing conditions are defined. The timing of symptoms, diagnosis and treatment should be compared with the wording rather than assuming that any earlier medical note automatically excludes the present claim.
What if my insurer says my condition has become chronic?
Some private medical policies primarily cover acute treatment and restrict ongoing management of chronic conditions. The insurer's decision should still be tested against the definition of chronic illness, the treatment being proposed and the medical evidence about its purpose.
Can an insurer refuse a claim because treatment was not pre-authorised?
That depends on the policy wording, the circumstances and whether the authorisation requirement was clearly applicable. The insurer may also need to consider whether it has suffered any real disadvantage and whether part of the treatment would otherwise have been covered.
Can I complain if my cover is through my employer?
The Financial Ombudsman says a beneficiary of an employer group private medical policy may still be able to complain about a claim. Complaints about the original sale of the group policy can be different because the employer is normally the policyholder.
Is the initial review free?
Yes. The initial review is free and there is no obligation to proceed. If further work appears appropriate, the proposed scope and pricing can be explained before you decide what to do next.