AXA PPP Healthcare Limited · DRN-6092992

The complaint Mr M is unhappy with AXA PPP Healthcare Limited’s (trading as AXA Health) decision to decline his claim. What happened Mr M has private medical insurance with AXA. He’d been receiving physiotherapy treatment, which AXA approved, however, AXA declined to pay the invoices related to his last four sessions. Mr M would like AXA to cover those costs. AXA said it approved the claim and paid the sessions up until the outpatient policy limit was exceeded. It said Mr M would need to fund the outstanding costs. Our investigator didn’t uphold this complaint. She said Mr M exceeded the policy limit of £3,000 and so AXA had declined the claim fairly. She noted Mr M may not have realised his allergy treatment in August 2024 reduced his outpatient limit. She highlighted AXA sent Mr M regular statements outlining medical invoices paid by the insurer and that it was for Mr M to monitor the remaining benefit available. Mr M’s policy year runs from 1 June – 31 May. Mr M, unhappy with that, asked for an ombudsman to review his complaint. In summary, he said his therapist authorised the final sessions with AXA directly and so it cannot change its position now. He also said it’s AXA’s responsibility to keep him informed of the remaining benefit under the policy. Mr M doesn’t accept the allergy testing reduced his outpatient limit as he was contacted by the provider to say the bill was unpaid. He said this issue is still actively in dispute with AXA. And so, it’s now for to 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 the same reasons as our investigator. The additional sessions being disputed exceeded the £3,000 outpatient limit and so there was so benefit left to pay for the sessions. AXA can, therefore, reasonably decline the claim on that basis. I understand Mr M has already paid the outstanding balance to his therapist, but AXA doesn’t need to reimburse his costs. I’ll explain why. The relevant rule that applies in this case comes from the Insurance Conduct of Business Sourcebook and says AXA must handle claims promptly and fairly and must not reject a claim unreasonably. I’ve considered AXA’s actions in line with this and other relevant industry guidelines. The main argument made by Mr M is that AXA approved his closing therapy sessions in February 2025. Mr M had also told his therapist he had £3,000 to spend on therapy and so he worked out the maximum number of sessions he could have. The issue with that was Mr M appeared to overlook the allergy treatment he had earlier in the policy year, in August 2024. That treatment reduced the available benefit under the policy limit and so Mr M had

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less than the £3,000 he initially thought. Mr M has made other arguments about whether AXA paid those invoices, but I won’t be considering that as he’s not raised it with the insurer. For the purposes of this complaint, AXA’s provided evidence that shows it paid the invoices related to Mr M’s allergy treatment on 4 and 18 September and a third invoice on 14 November 2024. Mr M highlighted AXA paid the final invoice much later than the date of his treatment. I should say insurers generally pay invoices subject to when the treatment provider submits them. So if a treatment provider doesn’t submit an invoice in good time, this could artificially show more available benefit. This can make it difficult for the insurer to provide up to date information about the limit remaining as not all treatment providers submit their invoices on time. This is also what happened when Mr M requested the four closing therapy sessions in February 2025. The evidence shows the insurer hadn’t been invoiced for treatment since December 2024. So, it appeared there was more benefit available than there was in reality. I say that because Mr M had continued to receive therapy sessions after December 2024, but the insurer hadn’t been invoiced yet. At the end of February 2025, AXA paid a large invoice for £595, which consumed most of the available benefit. That was the first invoice received in 2025. This meant he had £43 remaining of his benefit, which was used to pay part of his therapist’s costs when she submitted her March 2025 invoice. AXA said it cannot always know exactly how much of the allowance remains, particularly where there’s outstanding treatment that hasn’t yet been presented for payment. It said this is something Mr M ought to have been aware of and actively monitoring. And given what I’ve just explained, I think that’s reasonable as he was best placed to know he was continuing to receive treatment. At the time AXA approved the treatment, there was enough benefit available and so I don’t think it was unreasonable for the insurer to continue to approve Mr M’s requests in the circumstances. I’ve also seen that AXA sent Mr M regular statements outlining treatment it’d paid for and the benefit balance remaining after it’d settled those invoices. Mr M argued AXA should effectively carry the outstanding balance of his treatment costs across to the next policy year, but I don’t think that’s reasonable. Mr M’s policy year runs from 1 June – 31 May and so any treatment received during that time must be applied to the relevant policy year. My final decision My final decision is that I don’t uphold this complaint for the reasons I’ve explained. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr M to accept or reject my decision before 11 April 2026. Scott Slade Ombudsman

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