AXA PPP Healthcare Limited · DRN-6204533

The complaint X is unhappy with AXA PPP Healthcare Limited’s decision to decline his claim for treatment. What happened X has private medical insurance with AXA. In April 2025, he underwent cardiac intervention treatment for coronary artery disease. X was then referred for cardiac rehabilitation treatment, which he began without discussing with AXA. X said AXA unfairly declined his claim for cardiac rehabilitation. He said the treatment was medically necessary and without it, could end up costing AXA more in future as the treatment is aimed at improving his health. X would like AXA to accept his claim and pay for the rehabilitation treatment. AXA said whilst it doesn’t doubt this treatment is medically necessary, it considers it preventative, rather than actively treating a medical condition. AXA said the treatment is aimed at reducing the risk of future cardiac problems, through advice on smoking, diet and exercise. It said the policy excludes preventative treatment and therefore maintained its decision to decline the claim. Our investigator didn’t uphold this complaint. He said AXA had fairly relied on the exclusion to decline the claim. He said the medical evidence shows the treatment is focused on improving X’s longer-term health and managing coronary heart disease, which isn’t eligible treatment under the policy. X, unhappy with that, asked for an ombudsman to review his complaint. In summary, he said the policy’s definition of preventative treatment is inconsistent with that used by medical professionals. He maintains the treatment is necessary and that AXA should look to cover the claim. And so, it’s now for me to make a final decision. What I’ve decided – and why I’ve considered all the available evidence and arguments to decide what’s fair and reasonable in the circumstances of this complaint. Having done so, I’ve decided not to uphold it and for broadly similar reasons given by our investigator. Private medical insurance doesn’t cover every condition, nor does it seek to replace the NHS. AXA’s policy terms set out what it considers to be eligible treatment and explains treatment that’s not covered. AXA said cardiac rehabilitation treatment falls within the policy’s preventative exclusion criteria and I’m satisfied that’s correct. I’ll explain why. The relevant rule that applies in this case comes from the Insurance Conduct of Business Sourcebook (ICOBS) and says AXA must assess claims promptly and fairly and must not reject a claim unreasonably. I’ve considered this and other relevant industry guidance whilst assessing X’s complaint. Although I may not respond to every point X has raised, I want to reassure him I’ve considered everything he’s said. The informal nature of this service enables me to do that so I can resolve complaints with minimal formality.

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The starting point here is the policy terms and the exclusion AXA sought to rely on to decline X’s claim. The policy terms say: “What is not covered for preventative treatment and screening tests? We do not pay for: • preventative treatment, such as preventative mastectomy or a YAG laser iridotomy for narrow angles in isolation; or • preventative screening tests; or • routine preventative examinations and check-ups; or • tests to check whether: • you have a medical condition when you have no symptoms; or • you have a risk of developing a medical condition in the future; or • there is a risk of you passing on a medical condition. • tests where the result of the test wouldn’t change the course of eligible treatment. This might be because the course of eligible treatment for your symptoms will be the same regardless of the result of the test or what medical condition has caused them; or • preventative treatment or screening tests that themselves are not conventional treatment or where they are used to direct treatment that is not eligible treatment; or • any other preventative screening or treatment to see if you have a medical condition if you do not have symptoms; or • vaccinations” X said AXA’s interpretation of what it considers preventative treatment is at odds with practitioners in the medical field. I’ve considered his argument on that point, but it doesn’t persuade me AXA should accept and pay his claim. Whilst I accept there may be a more expansive definition among medical professionals, it’s AXA’s policy definition that applies in X’s case as those are the terms upon which the cover operates and which makes up the contract of insurance between X and AXA. The evidence shows the cardio rehabilitation treatment X claimed for is primarily focused on prevention of future disease by improving X’s health. It seeks to do this through advice on diet, exercise and health-related reviews. So, I think AXA can reasonably rely on the exclusion as I’m persuaded the treatment is preventative, as defined by the policy. X’s consultant cardiologist said this is routine treatment to improve X’s health, which whilst I accept is considered medically appropriate, further persuades me this is preventative treatment aimed at reducing the risk of developing a medical condition in the future. It’s for these reasons I think AXA can rely on the policy’s exclusion to decline X’s claim fairly. My final decision For the reasons I’ve explained, I don’t uphold this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask X to accept or reject my decision before 22 April 2026. Scott Slade Ombudsman

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