Upheld: claim denial based on alleged non-disclosure / misrepresentation complaint against AXA PPP Healthcare Limited
Financial Ombudsman decision DRN-6383336 of 2026-05-27T00:00:00+00:00. claim denial based on alleged non-disclosure / misrepresentation complaint against AXA PPP Healthcare Limited. Outcome: Upheld.
Decision detail
| Reference | DRN-6383336 |
|---|---|
| Decision date | 2026-05-27T00:00:00+00:00 |
| Firm | AXA PPP Healthcare Limited |
| Product | health insurance |
| Claim type | claim denial based on alleged non-disclosure / misrepresentation |
| Outcome | Upheld |
| Remedy | AXA PPP Healthcare Limited is directed to: (1) Remove the exclusion applied to the policy; (2) Reassess Mr L's claims cost on the basis that there was no qualifying misrepresentation, subject to remaining policy terms and limits; (3) Pay Mr L £750 compensation for distress and inconvenience caused by unnecessary worry about outstanding bills totalling approximately £60,000 over many months while dealing with his diagnosis and treatment. |
Summary
Mr L complained that AXA PPP Healthcare Limited unfairly declined his blood cancer treatment claim based on alleged non-disclosure of his MGUS diagnosis during the policy application. Mr L had been diagnosed with MGUS in 2015 and attended routine six-monthly blood tests for monitoring without symptoms or treatment. When he developed blood cancer in 2025, AXA initially covered treatment but then withdrew cover, claiming Mr L should have disclosed MGUS. The ombudsman upheld the complaint, finding that routine monitoring of a stable, diagnosed condition does not constitute 'treatment', 'consultation', 'diagnostic tests', or 'investigations' as defined in the policy questions, and therefore Mr L did not make a qualifying misrepresentation under CIDRA. AXA was directed to remove the exclusion, reassess the claim, and pay £750 compensation.
The Ombudsman's reasoning
The ombudsman applied CIDRA, which requires that for an insurer to rely on a misrepresentation, it must be a 'qualifying misrepresentation' - meaning the insurer would have offered different terms or declined the policy had the consumer taken reasonable care. The ombudsman found that Mr L was not receiving 'treatment' as defined in the policy (surgical or medical services needed to diagnose, relieve or cure a disease) but rather routine monitoring of a stable, diagnosed condition. The policy questions did not clearly require disclosure of monitoring appointments, and AXA failed to establish how the appointments were conducted or whether they involved specialist consultations. The ombudsman concluded that a reasonable consumer would not have considered routine blood tests for monitoring an already-diagnosed condition to constitute 'treatment', 'consultation', 'diagnostic tests', or 'investigations' as those terms were used in the policy. AXA had the opportunity to ask more specific questions but did not, and therefore failed to demonstrate a qualifying misrepresentation.
How this compares
| Group | Decisions | Uphold rate |
|---|---|---|
| AXA PPP Healthcare Limited, all decisions | 923 | 22% |
Source
Read the original decision on the Financial Ombudsman Service website