AXA Healthcare PPP Limited · DRN-6215407

The complaint Ms W complains that AXA Healthcare PPP Limited has turned down a claim she made on a group private medical insurance policy. What happened The background to this complaint is well-known to both parties. So I’ve simply set out a summary of what I think are the main events. Ms W is insured under a group private medical insurance policy. In December 2024, she took out a private antenatal package with a medical provider for reassurance purposes while she was pregnant. In February 2025, she was diagnosed with gestational diabetes (GD). In May 2025, Ms W made a claim on the private medical insurance policy for the costs of a caesarean section. But AXA turned down the claim. That’s because it said the policy didn’t cover pregnancy and childbirth other than the costs of treating a medical condition which arose during pregnancy. It didn’t agree that a caesarean section fell within the scope of policy cover. Ms W was unhappy with AXA’s position and she asked us to look into her complaint. Our investigator didn’t think AXA had treated Ms W unfairly. She felt it had been reasonable for AXA to conclude that the claim wasn’t covered by the policy terms. Ms W disagreed and so the complaint’s been passed to me to decide. 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, whilst I’m very sorry to disappoint Ms W, I don’t think it was unfair for AXA to turn down her claim and I’ll explain why. First, I’d like to reassure Ms W that while I’ve summarised the background to her complaint and her detailed submissions to us, I’ve carefully considered all that’s been said and sent. In this decision though, I haven’t commented on each point she’s made and I’m not required to by our rules. Instead, I’ve focused on what I think are the key issues. The relevant regulator’s rules say that insurers must handle claims promptly and fairly. And that they mustn’t turn down claims unreasonably. I’ve taken those rules into account, amongst other relevant considerations, such as regulatory principles, the policy terms and the available evidence, to decide whether I think AXA treated Ms W fairly. I’ve first considered the policy terms and conditions, as these form the basis of the insurance contract. Page eight of the handbook sets out key things AXA has chosen not to cover. This

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includes pregnancy and childbirth and notes: ‘Few health insurance plans cover pregnancy and childbirth because they are not illnesses, and the NHS is set up to deal with them.’ Page 34 of the handbook sets out the available, limited, cover in relation to pregnancy and childbirth. It says: ‘As pregnancy and childbirth are not medical conditions and because the NHS provides for them, our cover is limited. We don’t cover the checks or other interventions, such as antenatal and postnatal monitoring and screening, that you will have during pregnancy and birth. What is covered? We will cover the additional costs for treatment of medical conditions that arise during pregnancy or childbirth. For example: • ectopic pregnancy (pregnancy where the embryo or foetus grows outside the womb) • hydatidiform mole (abnormal cell growth in the womb) • retained placenta (afterbirth retained in the womb) • eclampsia (a coma or seizure during pregnancy and following pre eclampsia) • post partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth) • miscarriage requiring immediate surgical treatment.’ And pages 34 and 35 of the handbook explain that AXA won’t pay claims for preventative treatment. In my view, AXA has set out in a clear, fair and not misleading way that it doesn’t cover claims for pregnancy or childbirth unless they’re for the treatment of medical conditions which arise during pregnancy or childbirth. That means that in order for a claim to be paid under this section of the policy, a member must provide AXA with enough evidence to show that their treatment is aimed at treating a medical condition which has arisen during pregnancy or childbirth. I don’t agree that the terms are unclear or ambiguous. I appreciate AXA hasn’t set out an exhaustive list of what conditions it might consider to be covered under this part of the policy. But I think its list is indicative of the types of conditions it would generally cover. While AXA acknowledges that it was clinically necessary for Ms W to have a caesarean section, it doesn’t agree that her claim fell within the limited cover provided by the policy. I’ve therefore carefully considered whether I think this was a fair conclusion for AXA to draw. I’ve first looked closely at Ms W’s initial claim notification to AXA. She explained that she had a diagnosis of GD. She said: ‘Private obstetrician has advised that due to my GD, I need to have a caesarean pre 39 weeks. I want to have the caesarean privately as I have grave concerns regarding the NHS and my care and the care of my baby.’ AXA turned down the claim two days later. Ms W responded to say: ‘I will be going forth with the private planned c section given the seriousness of how NHS have inadequately dealt with my medical condition…especially as the NHS are clearly overrun & understaffed and not treating my case appropriately.’ Based on the evidence which was available to AXA at the outset, I don’t think it was unreasonable for it to conclude that Ms W was seeking a caesarean section because she

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was unhappy with the NHS. The evidence doesn’t indicate that Ms W needed a caesarean section to treat her GD – it appears it was more preventative in nature. In August 2025, some months after AXA’s decision to decline the claim, Ms W’s treating doctor wrote a letter in support of Ms W’s claim. They said: ‘(Ms W) needed to have a semi-urgent Caesarean section for her second child on the 16th May 2025. I had been concerned regarding (Ms W’s) changing sugar requirements in the context of gestational diabetes and also because the baby’s growth was starting to tail off. I therefore advised early Caesarean section. Because (Ms W) had had a previous Caesarean it would not have been safe to induce her in that situation. I therefore advised a Caesarean as the safest option which we did and the procedure was straightforward.’ The doctor’s letter makes it clear that Ms W’s sugar requirements had been impacted by her GD and that this concerned the doctor. But it also seems clear that the doctor was concerned about the baby’s growth rate. And I don’t think the letter is persuasive evidence that the caesarean was planned to treat GD – rather it seems to have been planned to avoid GD causing further complications for Ms W and her baby. As such, I don’t think it was unfair for AXA to conclude that the surgery was preventative in nature. I’ve also borne in mind the NHS guidance which both our investigator and Ms W have referred to. While it’s clear that earlier delivery is often recommended in cases of GD, it doesn’t seem that caesarean sections are required to treat the condition. So I don’t think it was unreasonable for AXA to find that the claim wasn’t covered by the policy. Taking the evidence into account, while I can entirely understand why Ms W chose to proceed with private surgery, I don’t think AXA unfairly concluded that it wasn’t covered by the policy terms. That’s because I don’t think the medical evidence shows, on balance, that the surgery was needed to treat Ms W’s GD. So while I sympathise with Ms W’s position and I appreciate she’s now suffering financial hardship, I don’t find it was unreasonable for AXA to turn down her claim. Ms W has referred to other costs she hasn’t yet claimed for. It’s open to her to make a retrospective claim for those costs should she wish to do so. I also understand she’s been unhappy with the response she’s received from AXA in relation to a claim for her child’s health. She may be able to make a new complaint to us about that issue once AXA has had a chance to look into it and issued its final response. My final decision For the reasons I’ve given above, my final decision is that I don’t uphold this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Ms W to accept or reject my decision before 23 April 2026. Lisa Barham Ombudsman

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