Not upheld: claim rejection / unfair claims handling complaint against AXA PPP Healthcare Limited

Decision detail

Summary

Miss D complained that AXA PPP Healthcare Limited unfairly rejected her claims for two surgical procedures authorised three days before they were scheduled. AXA rejected the left breast surgery as preventative treatment and the right breast surgery as treatment connected to previous cosmetic surgery. The ombudsman found both rejections were fair and reasonable under the policy's explicit exclusions for preventative treatment and cosmetic surgery-related treatment. The ombudsman upheld AXA's position that the left breast procedure was preventative and that the right breast implant replacement was excluded due to Miss D's prior cosmetic surgery. The complaint was not upheld and no remedy was ordered.

The Ombudsman's reasoning

The ombudsman applied industry rules requiring insurers to handle claims fairly and not unreasonably reject claims. For the left breast surgery, the available medical evidence clearly described the procedure as preventative treatment (risk reducing mastectomy), which is explicitly excluded under the policy terms. For the right breast surgery, although the temporary implant inserted during mastectomy is standard practice, the replacement of the original cosmetic implant is excluded under the policy's cosmetic surgery exclusions. The policy clearly states it does not cover treatment connected to previous cosmetic surgery. The ombudsman found these exclusions to be clear, unambiguous, and fair, and that AXA's previous 2024 communication to Miss D about this exclusion was also reasonable.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website