Upheld: unfair claim rejection / unreasonable reliance on policy exclusions complaint against AXA PPP Healthcare Limited

Decision detail

Summary

Mr and Mrs H complained that AXA unfairly declined a request for a specialist referral for their teenage daughter who had acne and unexplained hair loss. AXA initially rejected the referral, then agreed to cover it in November 2025, but reversed the decision in December claiming it did not cover alopecia. The GP had confirmed primary care had been exhausted and the referral was needed for diagnosis, with normal blood tests ruling out certain causes. The ombudsman upheld the complaint, finding AXA had not proven applicable policy exclusions applied and that the referral was for diagnostic purposes rather than cosmetic treatment. AXA was directed to accept the referral and pay £200 compensation for stress and inconvenience.

The Ombudsman's reasoning

The ombudsman applied relevant rules and industry guidelines requiring insurers to handle claims promptly and fairly without unreasonably rejecting claims. The ombudsman examined the policy exclusions for conditions treatable in primary care and cosmetic treatment. The evidence showed the GP had exhausted primary care options and confirmed an underlying medical cause needed specialist diagnosis. The ombudsman found AXA had not proven the exclusions applied, as the referral was for diagnosis rather than cosmetic treatment. AXA's reversal of its November agreement was unreasonable given the GP's confirmation that primary care had been exhausted.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website