Not upheld: claim rejection / policy exclusions interpretation complaint against AXA PPP Healthcare Limited

Decision detail

Summary

Mr K complained that AXA PPP Healthcare Limited unfairly refused to cover orthodontic treatment for his son under his private medical and dental insurance policy with additional Dentist and Optician cover. Mr K argued the policy terms were ambiguous and should be interpreted in his favour. The ombudsman found that the main policy terms clearly exclude specialist dental treatment including orthodontists, and the additional cover is limited to dentists and dental hygienists. The terms were sufficiently clear and not ambiguous, and there was no basis to direct AXA to depart from the policy terms. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that AXA's interpretation of the policy terms was not inconsistent or contradictory. The main policy terms clearly exclude cover for specialist dental treatment including orthodontists. The additional Dentist and Optician cover is limited to fees paid to dentists or dental hygienists and makes no mention of specialist treatment. The terms are not ambiguous as they specifically refer to the main policy terms and clearly limit the additional cover to dentists and dental hygienists. An orthodontist is reasonably classified as a specialist rather than a dentist or dental hygienist. There is no basis to direct AXA to depart from the policy terms.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website