Not upheld: claims handling delay complaint against AXA PPP Healthcare Limited

Decision detail

Summary

Mrs W claimed on her private health insurance policy for a blocked tear duct on 18 March 2025, but AXA failed to respond within its promised seven working day timeframe. After Mrs W chased in early May 2025, AXA responded with a medical information form request, but by then the policy was due to expire within a week and Mrs W chose not to renew due to high premiums. AXA accepted the delay and offered £100 compensation. The ombudsman found that even with a timely response, treatment would not have occurred before policy expiry due to the time needed for GP information, AXA assessment, and consultant availability, and that Mrs W should have chased earlier. The ombudsman upheld AXA's £100 compensation offer as fair and reasonable.

The Ombudsman's reasoning

The ombudsman accepted that AXA breached its obligation to respond within seven working days but found that even if AXA had responded promptly, treatment would not have taken place before the policy ended. The ombudsman reasoned that: (1) AXA would still have needed to request medical information from the GP, which typically takes two weeks; (2) AXA would then need to assess coverage and potentially request further information; (3) even if authorised, a consultant appointment may not have been available before policy expiry; and (4) Mrs W had a duty to mitigate losses by chasing AXA in late March/early April rather than waiting until early May. Therefore, the delay did not cause the loss Mrs W claimed.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website