Partially upheld: unfair application of policy exclusion and poor claims communication complaint against AXA PPP Healthcare Limited trading as AXA Health

Decision detail

Summary

Mr W, a beneficiary of a group private medical insurance policy with AXA Health, complained that AXA unfairly applied a chronic condition exclusion to limit his mental health treatment coverage after approximately 2 years of ongoing treatment. AXA had covered 84 therapy sessions and 27 psychiatrist consultations before deciding to withdraw cover, citing the chronic condition clause. The ombudsman found that AXA's application of the exclusion was fair and reasonable based on the duration and nature of the treatment, the clinical evidence, and the claim history. However, the ombudsman upheld the complaint in part, finding that AXA's communication regarding the withdrawal of cover could have been handled more sensitively given Mr W's vulnerability, and upheld the £200 compensation award for poor communication.

The Ombudsman's reasoning

The ombudsman found that AXA fairly applied the chronic condition exclusion clause because: (1) the treatment had been ongoing for approximately 2 years, demonstrating the condition required ongoing control or relief of symptoms; (2) the policy terms do not specify a time period before a condition is considered chronic, which is standard practice; (3) AXA's clinical review considered relevant medical evidence and the overall claim history; (4) limiting the psychiatrist appointments to 3 instead of the recommended 6 was reasonable given the claim history; and (5) AXA provided a reasonable timescale for Mr W to transition care. However, the ombudsman agreed that AXA's communication regarding the withdrawal of cover could have been handled more sensitively, particularly given the timing and Mr W's vulnerability, and that £200 compensation fairly reflected this failing.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website