Western Provident Association Limited · DRN-6204525

The complaint Mr B is unhappy with Western Provident Association Limited’s (trading as WPA) decision to decline his claim. What happened Mr B took a private medical insurance policy with WPA in June 2024. He made a claim a year later to see a specialist as he’d been suffering with symptoms of acid reflux and difficulty swallowing. He was diagnosed with a hiatus hernia. He’d like WPA to accept his claim for treatment. WPA said it declined Mr B’s claim because the condition was pre-existing. It said the medical evidence showed Mr B suffered with symptoms for three-years, which predated the policy’s inception. It relied on the moratorium underwriting clause to decline the claim. Our investigator didn’t uphold this complaint. He said Mr B hadn’t been symptom free for a continuous two-year period and therefore WPA declined his claim fairly as it was caught by the policy’s moratorium clause. Mr B, unhappy with that, asked for an ombudsman to review his complaint. In summary, he said the terms have been interpreted in a literal fashion which he doesn’t think is fair. He said that whilst he suffered symptoms of acid reflux (heart burn) and a lump in the throat sensation whilst swallowing, these were attributed to symptoms of asthma. Mr B said he wasn’t diagnosed with a hiatus hernia until June 2025, which was well within the period of cover. He also said the long-standing symptoms he suffered were non-specific and could have been attributed to any number of conditions. And so, it’s now for me to make a final 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. Having done so, I’ve decided not to uphold it and for similar reasons as our investigator. Private medical insurance doesn’t cover every medical condition. The terms upon which the policy is underwritten are the starting point for any claim. Mr B’s policy isn’t a medical history disregarded policy it’s underwritten on a moratorium basis. That means the policy won’t cover conditions that are pre-existing, unless Mr B was symptom free for a two-year period. The evidence shows Mr B continued to suffer with symptoms since his cover began and so I think WPA can reasonably rely on the moratorium underwriting to decline his claim. I’ll explain why. The relevant rule in this case comes from the Insurance Conduct of Business Sourcebook (ICOBS) and says WPA must handle claims promptly and fairly and must not reject a claim unreasonably. I’ve considered this, alongside other relevant industry guidance, whilst

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assessing Mr B’s complaint. I should also say that I’ve not addressed every point made by either Mr B or WPA, rather, I’ve focused on what I consider to be relevant to the crux of the issues complained about in this case. So, if I’ve not mentioned something specifically, it’s not because I haven’t seen it, I’ve chosen not to refer to it as part of my final decision. The rules that govern this service enable me to do that so that I can resolve complaints with minimal formality. The policy terms say: “Moratorium Underwriting … you will not be eligible to claim for treatment for at least two years, for any condition(s) which you had during the five years before your policy starts or which occurred in the first 14 days after you join us (the deferment period). We call these pre-existing conditions” And: “What is not covered Pre-existing conditions – subject to the underwriting of your Policy • Any condition, disease, illness or injury, whether symptomatic or not. This includes: - Anything for which you have received medication, advice or treatment; or - Where you have experienced symptoms, whether the condition has been diagnosed or not, before the start of your cover; or - Any symptoms or condition, whether diagnosed or not, which occurs in the first 14 days of cover, unless agreed and accepted by us in writing in advance” Having carefully considered Mr B’s claim and the available medical evidence, I’m persuaded it’s reasonable for WPA to conclude Mr B’s three-year history of acid reflux with every meal and sensation of a lump when swallowing are pre-existing conditions. This is documented on the specialist’s gastroscopy report and Mr B also confirmed he suffered with these symptoms prior to the policy’s inception. So, I think it’s reasonable for WPA to rely on the policy’s exclusion to decline the claim. Mr B said whilst he understands he suffered with these symptoms, they were initially thought to be related to asthma and that he’d not been diagnosed with a hiatus hernia before his cover began. I wanted to acknowledge Mr B’s argument about that, but it still doesn’t change my position on his complaint. I say that because Mr B didn’t need to receive a diagnosis for the symptoms that predated the policy for WPA to determine them as pre-existing. The policy terms define a pre-existing condition as any condition he has experienced symptoms for, whether the condition was diagnosed or not, that started before cover began. So, Mr B didn’t need to receive a diagnosis of hiatus hernia before the policy start date, he simply needed to experience symptoms of the condition for it to be considered pre-existing. WPA provided evidence to show Mr B’s symptoms of acid reflux and difficulty swallowing are associated with a hiatus hernia and so I’m persuaded this was the underlying cause, rather than Mr B’s asthma. It would also reasonably explain why the treatment Mr B received for his asthma didn’t resolve those symptoms and so I think WPA has declined his claim fairly in the circumstances. I know Mr B said the symptoms he experienced prior to the policy’s start date were broad and non-specific, but WPA has persuasively shown they are symptoms linked to his hiatus hernia condition. The NHS says acid reflux and difficulty swallowing are symptoms associated with the condition and so I think WPA can reasonably attribute them to Mr B’s hiatus hernia.

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My final decision For the reasons I’ve explained, I don’t uphold this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr B to accept or reject my decision before 20 April 2026. Scott Slade Ombudsman

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