Upheld: unfair application of policy exclusion complaint against AXA PPP Healthcare Limited

Decision detail

Summary

Ms T complained that AXA PPP Healthcare Limited unfairly added a muscular skeletal system exclusion to her private medical insurance policy following successful claims for hip pain, shin splints, and shoulder pain. AXA maintained the exclusion was fair under the policy's chronic condition terms, but the ombudsman found that Ms T had experienced several separate short-term acute conditions treated at different times, not a single chronic condition. The ombudsman considered Ms T's circumstances as a competitive sportsperson and young person experiencing puberty, and concluded AXA did not fairly apply the exclusion based on the available evidence. The complaint was upheld and AXA was directed to remove the exclusion from Ms T's policy.

The Ombudsman's reasoning

The ombudsman found that the evidence demonstrated Ms T experienced several separate short-term acute conditions rather than a single chronic condition. The policy terms define chronic conditions as requiring ongoing monitoring, control, or having no known cure. Ms T's conditions were treated as separate issues at different times, and the ombudsman was not persuaded that they amounted to generalised ongoing issues. The ombudsman considered Ms T's specific circumstances as a competitive sportsperson and young person experiencing puberty, and concluded that AXA did not fairly apply the exclusion considering the wider evidence they held.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website