Partially upheld: Travel / life insurance claim disputes complaint against AXA PPP Healthcare Limited

Decision detail

Summary

X, a stroke patient with AXA private medical insurance, sought to continue rehabilitation as an inpatient in a private hospital but was told by AXA in August 2025 that cover could be arranged post-discharge via GP referral. Following discharge from NHS hospital in September 2025, AXA declined his claim for private inpatient rehabilitation. The ombudsman found AXA's claim decline was correct under policy terms (X was medically fit for discharge and inpatient cover required hospital-to-hospital transfer), but AXA's August communication was unclear and conflicting. As a vulnerable consumer whose treatment decisions were made by family and medical professionals, X reasonably expected private inpatient rehabilitation to be available, supported by evidence of family discussions with AXA and private facilities. The ombudsman partially upheld the complaint, awarding £250 total compensation for loss of expectation and poor service, but rejected the £14,000 treatment cost claim as X remains entitled to 8 weeks outpatient rehabilitation and home-based treatment under the policy.

The Ombudsman's reasoning

Although AXA correctly declined the inpatient rehabilitation claim under the policy terms (X was medically fit for discharge and inpatient cover required hospital-to-hospital transfer), AXA's August 2025 communication was unclear and conflicting. The ombudsman found that X, as a vulnerable consumer whose treatment decisions were made by family and medical professionals, reasonably expected to receive private inpatient rehabilitation based on AXA's statements. Evidence of family emails to private facilities and discussions with AXA supported that X would likely have pursued private inpatient treatment had it been available. This created a loss of expectation warranting compensation. However, the ombudsman rejected the £14,000 claim cost as X remains entitled to 8 weeks outpatient rehabilitation and home-based treatment under the policy. The £10,000 compensation claim was rejected as X was not entitled to inpatient treatment and the ombudsman could not consider impact on family members.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website