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

Decision detail

Summary

Mr G claimed under his private health insurance policy for Percutaneous Hepatic Chemoperfusion (Chemosat) treatment for a rare form of cancer diagnosed in August 2024. AXA declined the claim on grounds the treatment did not meet the policy's definition of conventional treatment. The ombudsman found the treatment fell within AXA's Amber category (unproven but safe treatments) rather than being rejected outright, and that AXA should consider financial contribution up to equivalent conventional treatment costs. However, the ombudsman concluded that the alternative drug treatment suggested by Mr G's oncologist was not equivalent to the Chemosat system in terms of complexity, delivery method and risk profile, so no financial remedy could be awarded despite the complaint being upheld in principle.

The Ombudsman's reasoning

The ombudsman found that while the treatment does not meet the strict definition of conventional treatment (Green category), it falls within the Amber category of unproven treatments that are proven safe. Under the policy terms, AXA should consider making a financial contribution up to the cost of suitable equivalent conventional treatment for Amber category treatments. However, the ombudsman was not persuaded that the biological drug treatment recommended by Mr G's oncologist constitutes a suitable equivalent to the Chemosat system, as equivalency requires comparability in complexity, method of delivery, clinical purpose and risk profile, not merely treatments for the same condition. Since no suitable equivalent conventional treatment was identified, no financial remedy could be awarded despite the complaint being upheld in principle.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website