Vitality Health Insurance Claim Denied: How to Appeal in the UK

Vitality Health Insurance Claim Denied: How to Appeal in the UK

Vitality Health is one of the UK's leading private medical insurance (PMI) providers, known for its wellness-focused model that rewards healthy behaviour with premium discounts and rewards. Vitality is part of Discovery Group and serves hundreds of thousands of individual and corporate policyholders across the UK.

Despite the wellness-forward branding, Vitality denies claims like any other insurer — and when it does, you have strong rights to challenge those decisions through Vitality's internal complaints process and, if needed, the Financial Ombudsman Service (FOS).

About Vitality Health

Vitality Health offers:

• Personal Health Insurance (individual and family plans)
• Business Health Insurance (SME and corporate group schemes)
• Vitality Plus (enhanced plans with higher benefit limits)
• Cancer Cover and other condition-specific add-ons

Vitality's plans operate on a network model — policyholders receive treatment from Vitality's approved hospital network for the best coverage. Treatment outside the network typically incurs additional costs or may not be covered.

Common Vitality Health Denial Reasons

Pre-existing condition exclusions: This is the most common Vitality denial. Vitality's standard policies exclude conditions that existed before the policy started (moratorium or full medical underwriting exclusions). Common disputes include:

• Conditions that Vitality claims were "related to" a pre-existing condition
• Conditions the policyholder did not know they had pre-existing (symptom dating disputes)
• Conditions that fall within the moratorium period (typically 2 years)

Moratorium exclusions: Under moratorium underwriting, conditions you had in the 5 years before taking out cover are excluded for the first 2 years of the policy. After 2 continuous years without symptoms or treatment, the exclusion lifts. Disputes frequently arise about whether the exclusion period has passed or whether a current condition is "the same" as a prior one.

Not clinically necessary: Vitality may deny treatment it deems not clinically necessary according to its clinical criteria — similar to US medical necessity denials.

Out-of-network treatment: Treatment at a hospital outside Vitality's approved network typically is not covered by standard Vitality plans.

Waiting period exclusions: Some conditions have waiting periods before they are covered. Vitality may deny a claim if treatment occurs during a waiting period.

Cosmetic treatment: Vitality covers medically necessary treatment; purely cosmetic procedures are excluded.

Chronic condition limits: Vitality plans define which conditions are "chronic" (long-term conditions managed rather than cured). Coverage for chronic conditions is typically limited or structured differently.

Your UK Rights When Vitality Denies a Claim

FCA authorisation: Vitality is authorised and regulated by the Financial Conduct Authority (FCA). This means you have rights under the FCA's dispute resolution (DISP) rules.

Financial Ombudsman Service (FOS): After exhausting Vitality's internal complaints process, you can refer your complaint to the Financial Ombudsman Service — a free, independent dispute resolution scheme. The FOS handles thousands of health insurance complaints annually and has significant authority to direct insurers to pay out or reverse decisions.

Association of British Insurers (ABI) Code: The ABI's code of practice provides standards for how insurers should handle claims and complaints.

Limitation period: You typically have 6 years from the date of the disputed event to bring a legal claim (3 years for personal injury). FOS complaints must typically be made within 6 months of Vitality's final response.

Step-by-Step: How to Appeal a Vitality Denial

Step 1: Understand the Exact Denial Reason

Review Vitality's written denial carefully. Identify:

• Is this a pre-existing condition exclusion? If so, what is the alleged pre-existing condition?
• Is this a moratorium exclusion dispute?
• Is this a clinical necessity dispute?
• Is it an out-of-network issue?

Each requires a different appeal approach.

Step 2: Contact Vitality's Customer Services Team

Before filing a formal complaint, call Vitality's Customer Services (0808 178 1890 for health insurance) and ask:

• For the specific exclusion clause in your policy that applies
• For a copy of the relevant section of your policy wording
• Whether additional medical evidence might resolve the issue

Sometimes, providing additional medical documentation directly to a claims handler can resolve the denial without a formal complaint.

Step 3: Obtain Your Treating Doctor's Support

For clinical necessity denials:

• Ask your consultant/specialist to write a letter confirming the medical necessity of the treatment
• Request a letter from your GP supporting the referral
• Ask your specialist to explain why the specific treatment at the specific hospital is medically appropriate

For pre-existing condition disputes:

• Obtain a letter from your GP (and any relevant specialists) confirming the timeline of your symptoms and diagnoses
• If Vitality claims you had pre-existing symptoms, a GP letter challenging Vitality's symptom timeline can be decisive

Step 4: Submit a Formal Complaint to Vitality

If initial contact doesn't resolve the issue, submit a formal written complaint:

Vitality Customer Relations:

• Online: vitality.co.uk (member portal complaints section)
• Email: customerrelations@vitality.co.uk
• Post: Vitality, 3 More London Riverside, London, SE1 2AQ
• Phone: 0808 178 1890

In your complaint:

• State clearly that you are making a formal complaint
• Reference your policy number and claim number
• Explain the denial and why you believe it is incorrect
• Attach all supporting medical evidence
• Request a specific outcome (pay the claim, lift the exclusion)

Vitality must acknowledge your complaint within 5 business days and issue a Final Response within 8 weeks (or sooner if they have investigated).

Step 5: Escalate to the Financial Ombudsman Service (FOS)

If Vitality's Final Response does not resolve your complaint (or if Vitality fails to respond within 8 weeks):

File a complaint with the FOS:

• Online: financial-ombudsman.org.uk
• Phone: 0800 023 4567 (free from landlines)
• Email: complaint.info@financial-ombudsman.org.uk
• Deadline: Within 6 months of Vitality's Final Response

The FOS is free for consumers and has wide authority to direct insurers to pay valid claims, uphold complaints, and award compensation. The FOS deals with hundreds of private medical insurance complaints each year and is particularly effective for:

• Pre-existing condition exclusion disputes (FOS considers whether Vitality applied the exclusion fairly)
• Moratorium exclusion timeline disputes
• Clinical necessity decisions that appear to apply overly restrictive criteria

Step 6: Consider Independent Arbitration or Legal Action

For very large claims, you may consider:

• Independent Medical Expert: If the dispute is about clinical necessity, an independent expert opinion can be compelling both for FOS and in court
• Legal action: County Court or High Court claims are available for breach of insurance contract

Vitality-Specific Tips

Moratorium reviews: If your 2-year moratorium period has passed, contact Vitality proactively to have exclusions reviewed. Vitality may not automatically remove them.

Cancer cover: Vitality has specific cancer diagnosis and treatment pathways. If a cancer-related claim is denied, ensure your treating oncologist has referred you through Vitality's cancer care pathway.

Second surgical opinion: For denied surgery, ask Vitality if they will fund a second surgical opinion from a Vitality-approved consultant. This can sometimes resolve disputes.

Pre-authorisation: Always obtain Vitality's pre-authorisation before elective treatment. Failing to do so gives Vitality grounds to deny the claim that may be difficult to overcome.

FOS success rate for health insurance complaints: Approximately 30–40% of FOS health insurance complaints are resolved in the consumer's favour. This is a meaningful proportion — don't be deterred from escalating.

Conclusion

Vitality Health denials — particularly pre-existing condition exclusion disputes and moratorium disputes — are some of the most contested in UK private medical insurance. But the Financial Ombudsman Service provides a free, accessible, and genuinely independent route to challenge Vitality's decisions. Don't accept a Vitality denial without fully exhausting the complaints process and escalating to the FOS if necessary. Use ClaimBack at claimback.app to generate a professional complaint letter for your Vitality Health dispute.

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Related Reading:

• Aviva Health Insurance Claim Denied: How to Appeal in the UK
• AXA Health (PPP) Claim Denied: How to Appeal in the UK
• Bupa Claim Denied: How to Appeal
• Insurance Bad Faith: Your Rights When an Insurer Wrongfully Denies