Not upheld: Travel / life insurance claim disputes complaint against AXA PPP Healthcare Limited

Decision detail

Summary

Mr D complained that AXA PPP Healthcare Limited unfairly rejected his claim for a chiropractor referral for back pain under his group private medical insurance policy. AXA PPP declined the claim based on medical information indicating the back pain was a pre-existing condition not covered by the policy, which excludes conditions from the five years prior to joining unless specific conditions are met. Mr D subsequently claimed the referral was for a slouch, but AXA PPP rejected this as not constituting medical treatment. The ombudsman found AXA PPP acted fairly and reasonably, as the GP medical forms indicated the condition existed before the policy started, and noted that AXA PPP had corrected an initial authorisation error and paid the GP's fee. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that AXA PPP acted fairly in declining the claim because the medical evidence from the GP forms indicated that Mr D's back pain was likely a pre-existing condition, having been present for a few weeks before the policy started on the same day as the initial consultation. The policy explicitly excludes pre-existing conditions unless specific conditions are met. Additionally, even if the claim were for a slouch rather than back pain, this would not constitute 'medical treatment' under the policy definition, and the evidence suggested it was also a pre-existing issue. The ombudsman noted that AXA PPP had corrected its initial error in authorising the referral and had paid the GP's fee, which was beyond normal expectations.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website