Not upheld: claim rejection - conflicting information and lack of medical evidence complaint against AXA PPP

Decision detail

Summary

Miss P complained that AXA PPP unfairly rejected her private medical insurance claim for varicose vein treatment. AXA initially declined the claim as cosmetic, then declined a subsequent claim citing conflicting information about Miss P's symptoms. Miss P had initially told AXA she had no pain, but approximately one month later claimed she had experienced pain and tingling for 6-7 months. The ombudsman found AXA acted fairly because the policy only covers treatment where medically necessary and not cosmetic, and AXA applies this consistently. The ombudsman was not satisfied by Miss P's explanation for the contradictory statements and noted the absence of contemporaneous medical evidence supporting her account of prolonged symptoms. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman applied regulatory rules requiring insurers to handle claims fairly and not unreasonably reject claims. The policy legitimately limits coverage to medically necessary treatment that is not cosmetic, and AXA applies this consistently. The critical issue was Miss P's contradictory statements: she initially stated no pain, then later claimed 6-7 months of symptoms. The ombudsman found this contradiction unexplained and noted the lack of contemporaneous medical evidence supporting the later account. The Consultant's letter, based on Miss P's self-reporting after AXA's initial rejection, was insufficient to override the policy terms and the conflicting information provided.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website