Not upheld: unfair claim decline - fertility treatment coverage complaint against AXA PPP Healthcare Limited

Decision detail

Summary

Mr L complained that AXA PPP Healthcare Limited unfairly declined fertility treatment costs claimed under his group private health insurance policy. AXA covered semen analysis relating to Mr L but declined costs for medication, tests and treatment administered to his wife, as well as two invoices for 'TFP Freeze all and transfer cycle' treatment totalling over £13,000. The ombudsman found that AXA fairly declined the costs because Mr L's wife was not a named beneficiary of the policy, and the policy terms limit coverage to named beneficiaries. The ombudsman rejected arguments that the policy was discriminatory or misleading, and found no unfairness in AXA's initial misunderstanding about the freeze all cycle, as it was promptly corrected. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that AXA fairly declined costs relating to Mrs L's treatment because she was not a named beneficiary of the policy. The policy terms clearly define coverage as applying to 'the lead member and any family members covered by the plan', and Mrs L was not listed as a covered family member. While the ombudsman acknowledged that fertility treatment involves both partners, the policy terms limit coverage to named beneficiaries, and it would not be reasonable to expect an insurer to cover costs for someone not insured under the policy. The ombudsman rejected arguments that the policy was discriminatory or misleading, noting that male beneficiaries can still benefit from fertility cover (as demonstrated by AXA's coverage of Mr L's semen analysis). The ombudsman also found no unfairness in AXA's initial misunderstanding about the freeze all cycle, as it was promptly corrected and the costs were fairly declined on the correct basis.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website