Not upheld: Home insurance claim disputes complaint against AXA PPP Healthcare Limited

Decision detail

Summary

Mr S complained that AXA PPP Healthcare Limited failed to fully cover his treatment costs under his private medical insurance policy. Specifically, AXA declined to cover specialist consultations beyond the policy limit of two per policy year, which Mr S exceeded. The ombudsman found that the policy limit was clearly explained to Mr S and his wife, and that AXA acted reasonably in applying the policy terms as written. Although Mr S argued it was unreasonable to attend a consultation without returning for results, and claimed AXA had treated other appointments more generously, the ombudsman determined these arguments did not justify departing from the policy terms. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that AXA acted in accordance with the policy terms by limiting specialist consultations to two per policy year. The policy limit was clearly explained to the policyholder, and AXA is entitled to apply the terms as written. The fact that AXA may have billed other appointments differently does not mean they acted unreasonably in this case, as any previous more generous treatment would be to the policyholder's advantage but does not obligate them to exceed policy terms.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website