Not upheld: policy terms interpretation / cover reinstatement refusal / alleged mis-selling complaint against AXA PPP Healthcare Limited

Decision detail

Summary

Mrs J complained that AXA PPP Healthcare Limited refused to reinstate outpatient cover on her private medical insurance policy and that she should have been told in 2020 that reinstatement would not be possible. Mrs J had switched from a 'Key' plan to an 'Assure' plan in January 2021 to reduce premiums, which removed her £750 outpatient allowance. The ombudsman found that the policy terms clearly stated cover changes could only be made at renewal and were subject to underwriting and medical restrictions. The call handlers in December 2020 clearly explained the impact of the change, and Mrs J made an informed decision to proceed. The ombudsman concluded that AXA could not have accurately told Mrs J in 2020 whether future reinstatement would be possible, and therefore did not uphold the complaint.

The Ombudsman's reasoning

The ombudsman found that the policy terms clearly and fairly set out that cover changes could only be made around renewal dates and were subject to underwriting criteria and medical restrictions. The call handlers in December 2020 clearly explained the impact of removing outpatient cover and Mrs J chose to proceed to reduce her premium. The ombudsman concluded that AXA could not have accurately told Mrs J in 2020 whether future reinstatement would be possible, as this would depend on future medical conditions and underwriting decisions. AXA did not mislead Mrs J or make errors in administering her plan.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website