AXA PPP Healthcare Limited · DRN-6199842

The complaint Mrs A is unhappy that AXA PPP Healthcare Limited declined a claim for treatment made on her private health insurance policy. What happened The details of this complaint are well known to both parties, so I won’t repeat them again here. I’ll focus on giving the reasons for my 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. That includes AXA’s regulatory obligation to handle insurance claims fairly and promptly. And to not unreasonably decline a claim. I have a lot of empathy for Mrs A’s situation. She feels very strongly that AXA hasn’t acted fairly and reasonably here. I know she’ll be disappointed but for the reasons set out below, I don’t uphold her complaint. The policy terms say: When you join, you won't be covered for treatment of any conditions you had in the three years before you joined this plan. This includes if you had symptoms of a condition that hadn't been diagnosed. Once you've been trouble-free from that condition for at least two years in a row after the date you joined, we can start covering treatment of these conditions. We'll count you as ‘trouble free' when you haven't gone to a medical practitioner, including a physiotherapist, or had any treatment or advice for your condition for two years [my emphasis]. I’ll refer to this as “the pre-existing condition exclusion”. The policy started in September 2025. Around six weeks later (in October 2025), a private gynaecological referral was made for suspected pelvic organ prolapse. It’s reflected that Mrs A reported: heaviness “down below” for the past three to four weeks and needing to occasionally push during urination over the last year. A consultant gynaecologist and specialist in urogynaecology then provided a letter dated 13 November 2025 which referred to Mrs A’s symptoms, including “she sometimes has to push hard to empty her bladder”. That consultant also provided a follow-up letter dated 28 November 2025 reflecting that Mrs A had been in touch to say that there were a few things they’d misunderstood during the consultation and needed correcting. That included “the symptom of having to push to empty your bladder…was a recent symptom”.

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Mrs A also saw another consultant gynaecology and obstetrician, and they provided a letter dated the end of November 2025 setting out some of Mrs A’s symptoms and that included “incomplete emptying of the bladder”. Based on the overall medical evidence from that time, I’m satisfied that it’s reasonable to conclude that the reference to “needing to occasionally push during urination over the last year” in October 2025 is consistent with Mrs A’s reported symptom of having to push to empty the bladder / incomplete emptying of the bladder in the subsequent consultant letters dated November 2025. I’ve taken into account what Mrs A says about this not being the presenting symptom she was worried about and had sought advice for. However, I’m satisfied that AXA has fairly and reasonably concluded that she had the symptom of having to push to empty her bladder before the policy started. The NHS website reflects that pelvic organ collapse may not cause any symptoms. But if someone does have symptoms they can include: “problems peeing, such as feeling like your bladder is not emptying fully”. I’ve also considered that the second consultant Mrs A met with has recently answered Mrs A’s query about whether an isolated comment of occasionally needing to push during urination (without any other urinary symptoms) would be sufficient to establish a prior symptomatic pelvic organ prolapse (in relation to her later diagnosis). The consultant replied that it was difficult comment on a specific case but in general “this can happen without the presence of a prolapse”. That may be the case. However, the second consultant doesn’t say, in their opinion, that this symptom wasn’t related to the later diagnosis. So, I don’t think what’s said is inconsistent with this being a symptom of pelvic organ prolapse. And although Mrs A has explained that she has another medical condition which may result in her urinary symptom and she didn’t give it much notice at the time, given the overall medical evidence and what’s reflected on the NHS website, I’m satisfied AXA has fairly and reasonably relied on the pre-existing condition exclusion to decline covering any further medical costs relating to pelvic organ prolapse. Other issues I understand AXA had approved and covered the cost of the initial investigation into her condition before declining to cover any further costs. It said this was covered in error, and it won’t seek to recover the costs back from Mrs A. I think that’s fair and reasonable. Mrs A has benefitted from the initial cover of a condition that AXA has (fairly) concluded wasn’t covered under the pre-existing condition exclusion. My final decision I don’t uphold this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mrs A to accept or reject my decision before 20 April 2026. David Curtis-Johnson Ombudsman

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