Health insurers turn down claims on grounds such as a pre-existing condition, information they say you left out when you applied, or what the policy terms cover, and a refusal can be challenged. If you complain, the insurer must look into it and send you a final response, and if you are still unhappy the Financial Ombudsman Service, which is free to use, can look at the claim again. This page sets out why claims get refused, the order in which to challenge a refusal, and which bodies regulate insurers. If your doubt is about the policy itself, an FCA-authorised broker will lay the clause that sank your claim beside other insurers' wording on a no-fee phone call, which the form on this page books for you.
The reasons a private medical claim gets refused
An insurer decides a claim against the wording of your policy. The Financial Ombudsman Service, which deals with complaints about private medical and dental insurance, sets out the grounds that come up in the complaints it sees in its pages on pre-existing conditions and on misrepresentation.
- A pre-existing condition. The Ombudsman defines it as "an illness or injury you had before your policy began or was renewed". It reports complaints from people who say their insurer "won't accept their claim because it's linked to a pre-existing medical condition". Some policies are individually underwritten, so the insurer asked about your health when you applied. Others carry a blanket exclusion for anything related to a condition you already had. The page on pre-existing conditions explains how the two routes differ.
- Something the insurer says you did not tell it. When you claim, an insurer may find something it believes suggests you misrepresented or did not disclose information when you took the policy out.
- A change in health. The Ombudsman notes that an insurer "may turn down a claim because of a condition that came after the policy began or was renewed". Usually you only have to give an insurer information when you buy or renew, though your policy terms might say you need to tell it about changes.
- The policy terms themselves. The Ombudsman looks at what the policy says, including what the insurer asked you about your health when you took out, changed or renewed the cover.
Waiting periods, benefit limits and excesses can also decide whether a given bill is paid; the waiting periods page explains the first of these. Start with the reason the insurer gives for refusing, because that is what any challenge has to answer.
Challenging the refusal, step by step
- Complain to the insurer first. The Ombudsman says the business should have the chance to sort things out, and that you should tell it what happened and how you would like it put right. Contact details are usually in its terms and conditions, on its website or in paperwork it has sent you.
- Keep records. It advises keeping a note of conversations and correspondence, because that helps it work more quickly if the complaint reaches it.
- Wait for the final response. For most complaints a business has up to 8 weeks to consider a complaint. Its final response should give the outcome and explain how to take the complaint further.
- Go to the Ombudsman. You can do so if you have a final response and are unhappy with it, or if the time limit has passed without a reply. You need to complain to the Ombudsman "within 6 months from the date on your final response", so keep the letter and note the date.
How long the Ombudsman then takes depends on what the complaint is about and how complex it is. Tell the insurer early if you are severely ill or in financial difficulty: depending on the circumstances, it may be able to look at the complaint more quickly.
Can an insurer withdraw a claim it first accepted?
This is the worry behind searches such as whether insurers can deny a claim after approval, and the Ombudsman's page on misrepresentation is the nearest source. It says that if an insurer decides you gave it incomplete or misleading information, it might charge more, apply a restriction retrospectively, settle a claim proportionately, or avoid the policy, which "means any ongoing claim will be declined". These options are not automatic. The Ombudsman looks at whether the insurer's questions were clear, whether you took reasonable care to answer them, and whether the insurer would have acted differently with the right answers.
Where the mistake was careless, it says the insurer's response should rest on what it would have done had you answered correctly. It also notes that where a misrepresentation comes to light a year or more on, and the insurer would not have offered cover originally, it may avoid the original contract and reject claims from that first period; it can only avoid later renewals if you misrepresented again then and that made a difference. If an insurer carries on with the contract after learning of the problem, the Ombudsman generally thinks it unfair to change its mind later. Whether a pre-authorisation changes any of this depends on the wording of your own policy. Should the refusal leave you doubting that policy, this page's form gets you a free phone call from a broker, who can compare how other insurers word the point in dispute.
What the Ombudsman can ask an insurer to do
If it concludes a claim was unfairly turned down, the Ombudsman says it may recommend that the insurer reconsider the claim in line with the policy terms, or pay the claim and add interest from the date of the claim until it is settled. If the policy was mis-sold because you were not made aware of an exclusion, it may ask for the premium to be refunded with interest, less any tax due. It can also consider an award for distress and inconvenience. If it decides the insurer acted fairly, the refusal stands, so nothing here is a promise that a complaint will succeed.
Who regulates health insurers, and where to take a complaint
Two regulators oversee insurers. The Financial Conduct Authority says it regulates financial services firms in the UK and sets standards for them, including the Consumer Duty, which it describes as meaning consumers should get "products and services that meet their needs and offer fair value". It works alongside the Prudential Regulation Authority, "the prudential regulator of around 1,500 banks, building societies, credit unions, insurers and major investment firms". For an insurer, that means the FCA regulates its conduct, including how it treats customers, while the PRA is its prudential regulator, concerned with whether it is financially sound.
Neither regulator settles an individual dispute about your claim; the Ombudsman does that, after the insurer has had its chance. The FCA register lists the contact details of regulated firms and also lets you check that a firm is authorised. A refusal letter is easier to read against the policy wording with a second pair of eyes, and asking for a broker's call-back through this page costs nothing.
Questions readers ask after a refusal
Do I need a solicitor or a claims company to complain?
No. The Ombudsman says you do not need to pay anyone to represent you, though you can ask a family member, friend or someone else to help.
Is private medical insurance covered by the Ombudsman?
Yes. Its pages list private medical insurance and dental insurance among the policies it can help with, and say it may be able to assist with a complaint about a policy or a claim.
Can I use AI to write my complaint?
The Ombudsman says it helps to hear what happened in your own words, and warns that AI tools can get things wrong or add legal-sounding arguments that are not accurate. If you do use one, it advises against entering health or banking information you would not want shared.
What if my claim was refused because the insurer says my condition was already there?
If your insurer never asked about your health and there was no medical screening, the Ombudsman says it will consider whether it was fair to use the exclusion. If there was screening, it checks whether you gave the insurer all the relevant information.
Sources: Financial Ombudsman Service pages on how to complain (read 26 October 2026), misrepresentation and non-disclosure (read 26 October 2026), pre-existing medical conditions (read 29 October 2026), insurance (read 27 October 2026) and medical insurance (last updated 28 July 2026, read 1 November 2026); About the FCA, fca.org.uk (last updated 9 July 2026, read 1 November 2026).