Not upheld: claim decline - exclusion of cosmetic/non-medically necessary treatment and related investigations complaint against AXA PPP Healthcare Limited (trading as AXA Health)

Decision detail

Summary

Mr P complained that AXA PPP Healthcare Limited unreasonably declined his claim for removal of a lump and associated diagnostic tests under his private medical insurance policy. AXA declined the claim on the basis that removal of fat or surplus tissue is excluded under the policy terms, and that investigations related to ineligible treatment are not covered. The ombudsman found that Mr P's condition had been previously diagnosed as a benign lipoma by his own GP approximately two years prior, and this was supported by AXA's virtual GP assessment. The ombudsman was satisfied that AXA correctly applied its internal clinical criteria in declining cover, as there were no indicators of clinical urgency such as rapid growth or persistent pain. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman considered the policy terms which exclude removal of fat or surplus tissue and exclude investigations related to ineligible treatment. The ombudsman found that Mr P's condition had been reasonably established as a benign lipoma by his own GP approximately two years prior, and this assessment was supported by AXA's virtual GP examination. The ombudsman was satisfied that AXA correctly applied its internal clinical criteria in declining cover, as the lump showed no characteristics suggesting clinical urgency (no rapid growth, no persistent pain). The ombudsman found AXA's offer to reconsider if Mr P provided medical records to the contrary was reasonable.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website