Upheld: unreasonable claim decline - misapplication of pre-existing condition exclusion and alcohol misuse exclusion complaint against AXA PPP Healthcare Limited
Financial Ombudsman decision DRN-6300503 of 2026-05-12T00:00:00+00:00. unreasonable claim decline - misapplication of pre-existing condition exclusion and alcohol misuse exclusion complaint against AXA PPP Healthcare Limited. Outcome: Upheld.
Decision detail
| Reference | DRN-6300503 |
|---|---|
| Decision date | 2026-05-12T00:00:00+00:00 |
| Firm | AXA PPP Healthcare Limited |
| Product | private medical insurance |
| Claim type | unreasonable claim decline - misapplication of pre-existing condition exclusion and alcohol misuse exclusion |
| Outcome | Upheld |
| Remedy | AXA must: (1) pay Mr P's claim in full subject to policy limits and applicable excess; (2) pay 8% simple interest per year on any costs already paid by Mr P from the date paid until settlement; (3) pay £300 compensation for unreasonable decline of the claim and associated distress and inconvenience. |
Summary
Mr P claimed for private hospital treatment received in April 2025 for acute cholecystitis with cholangitis, common bile duct stone, and cirrhosis. AXA initially declined citing alcohol misuse and pre-existing liver disease, then changed its position to rely on a moratorium clause after an incidental gallstone finding from March 2023. The ombudsman upheld Mr P's complaint, finding the gallstone was asymptomatic with no documented advice or treatment, therefore not a pre-existing condition under policy terms. Specialist medical evidence confirmed biliary sepsis, not alcohol, caused the liver decomposition. AXA was ordered to pay the claim in full plus 8% interest and £300 compensation.
The Ombudsman's reasoning
The ombudsman applied ICOBS rules requiring claims to be assessed promptly and fairly without unreasonable rejection. The policy definition of pre-existing conditions requires evidence of symptoms, advice, medication or treatment within five years before cover started. The March 2023 gallstone was an incidental, asymptomatic finding with no documented advice or treatment, therefore it did not meet the policy definition. Specialist medical evidence consistently established that biliary sepsis, not alcohol misuse, caused the liver decomposition. The March 2023 CT scan showed normal liver morphology, and Mr P showed no clinical signs of alcohol-related complications during hospitalization. AXA's arguments were speculative and unsupported by contemporaneous medical evidence.
How this compares
| Group | Decisions | Uphold rate |
|---|---|---|
| AXA PPP Healthcare Limited, all decisions | 923 | 22% |
Source
Read the original decision on the Financial Ombudsman Service website