AXA PPP Healthcare Limited · DRN-6120142

The complaint Mrs B complains about a claim made with AXA PPP Healthcare Limited (‘AXA’) under her private medical insurance policy. Both Mrs B’s claim and her complaint to our Service were brought by a representative who holds power of attorney for her. For ease of reading, I’ve referred mainly to Mrs B throughout this final decision. What happened Mrs B is insured under a private medical insurance policy, provided by AXA. Mrs B contacted AXA to make a claim for eye surgeries (ptosis and blepharoplasty). AXA said it would require a GP referral letter, amongst other information, but later said the policy didn’t cover blepharoplasty. After Mrs B provided further information to AXA, it said ptosis wouldn’t be covered either. But AXA later changed its position and said it would cover ptosis for Mrs B’s right eye but not her left. Unhappy, Mrs B complained to AXA. AXA maintained its position about the claim but paid Mrs B £65 for the cost of a vision test as a gesture of goodwill because of the incorrect information she’d been given. As Mrs B remained dissatisfied, she brought the matter to the attention of our Service. One of our Investigators looked into what had happened. She said she thought AXA should pay for Mrs B’s left eye ptosis as well as £150 compensation for the distress and inconvenience she’d experienced. AXA didn’t agree with our Investigator’s opinion, so the complaint has now been referred to me to make a decision as the final stage in our process. 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. Industry rules set out by the regulator say insurers must handle claims fairly and shouldn’t unreasonably reject a claim. I’ve taken these rules, alongside other relevant considerations such as Consumer Duty principles, into account when making this final decision. The terms and conditions of Mrs B’s policy exclude the following: ‘We do not cover the removal of fat or surplus tissue … whether or not the removal is needed for medical or psychological reasons.’ The NHS describes blepharoplasty as surgery to remove excess skin or fat from the eyelids. So, I don’t think it’s unfair or unreasonable for AXA to consider this surgery as being

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excluded under Mrs B’s policy. I’ve considered Mrs B’s comments about AXA’s ‘Schedule of Procedures’ on its website. I don’t think it’s unfair or unreasonable for AXA to set out covered procedures in this way, in a list which can be updated and changed, rather than in a set printed format. But, regardless of what finding I reach on this point, I don’t think blepharoplasty is covered under the policy anyway because of the exclusion I’ve mentioned above. AXA says only Mrs B’s right eye ptosis surgery is covered under the policy. AXA says it considers left eye ptosis surgery to be preventative treatment (and therefore excluded under the policy) because Mrs B’s left eye ‘does not have significant pupil coverage’. If AXA is seeking to rely on a policy exclusion relating to preventative treatment and/or that left eye ptosis surgery is not medically necessary, then it’s for AXA to demonstrate the exclusion(s) apply. AXA also needs to satisfy me that it has treated Mrs B fairly in making its decision about her claim, and that any other policyholders in the same situation would be treated in the same way. I don’t think AXA has done any of this. It's not for me to seek to interpret Mrs B’s eye test results myself. I’m not a medical expert, and it wouldn’t be appropriate for me to do this. Instead, I’ve considered the available medical evidence to decide whether I think AXA acted fairly and reasonably when relying on this to make the decision it did. I accept the initial letter from Mrs B’s optometrist dated 17 March 2025 referred only to right ptosis surgery. However, a subsequent letter from the optometrist dated 16 June 2025 says ‘left upper lid obscuring top portion of pupil’ and Mrs B would ‘benefit from ptosis correction’. A report from Mrs B’s Consultant Ophthalmic and Oculoplastic Surgeon dated 9 July 2025 says ‘I have recommended we proceed with bilateral upper lid ptosis surgery. This would be for functional reasons.’ I think the letters of June 2025 and July 2025 carry significant evidential weight in demonstrating that Mrs B requires ptosis surgery on her left eye. I’ve carefully thought about the clinical advisor notes which AXA provided in support of its position, but I don’t find these persuasive. The notes don’t set out information such as the qualifications of the advisor, what medical evidence has been considered and give no detail other than to say ‘ptosis procedure to L eye is not eligible.’ The commentary provides no specific reason why left eye ptosis isn’t eligible and/or what the parameters for coverage of this procedure are. AXA hasn’t provided details of its internal criteria for the coverage of ptosis surgery in response to a request from our Service. And, even if I accept that ptosis surgery is only covered under AXA’s internal criteria if there is ‘significant pupil coverage’, AXA has provided no information about what it considers to be ‘significant’. So, I can’t be satisfied that Mrs B has been treated fairly. Taking into account the medical evidence provided by Mrs B, I don’t think AXA has demonstrated either that the left eye ptosis surgery is preventative treatment or that it isn’t medically necessary. AXA also hasn’t demonstrated that it has clear and consistent internal criteria which it applies to claims for ptosis surgery to satisfy me that Mrs B has been treated in the same way as any other policyholder in the same situation would have been. This means I don’t think AXA acted fairly or reasonably by declining Mrs B’s claim for left eye ptosis surgery. So, AXA should now accept the claim.

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AXA was reasonably entitled to request a GP referral letter and other supporting evidence from Mrs B before authorising any claim. And I don’t think it would be reasonable or appropriate for AXA to have accessed different policy information in an attempt to obtain Mrs B’s representative’s contact details. But, having said that, I don’t think AXA handled other aspects of the claim as I’d have expected it to. AXA gave incorrect information to Mrs B on two occasions, and I don’t think the £65 which it has paid fairly reflects the distress and inconvenience Mrs B has experienced as a result of how it handled the claim. I have no power to award compensation to Mrs B’s representative for any distress and inconvenience which she herself experienced as a result of how this claim was handled. I can only award compensation to an eligible complainant. Mrs B’s representative isn’t insured under this particular policy, so she isn’t an eligible complainant in her own right for the purposes of this complaint. However, although Mrs B’s representative may have borne much of the inconvenience in dealing with AXA about the claim, I’m satisfied the situation also affected Mrs B directly and I think it would be fair and reasonable in the circumstances for AXA to pay compensation for the impact of this. In particular, Mrs B lost the opportunity to have the left eye ptosis carried out at the same time as her right eye surgery. Overall, I think it would be fair and reasonable in the circumstances for AXA to pay Mrs B an additional £150 compensation for the distress and inconvenience she experienced. Putting things right AXA PPP Healthcare Limited needs to put things right and do the following: • accept Mrs B’s claim for ptosis surgery on the left eye, subject to any applicable policy limits and/or excess: • pay Mrs B an additional £150 compensation for the distress and inconvenience she experienced. My final decision My final decision is that I’m upholding Mrs B’s complaint about AXA PPP Healthcare Limited and I direct it to put things right in the way I’ve outlined above. Under the rules of the Financial Ombudsman Service, I’m required to ask Mrs B to accept or reject my decision before 18 March 2026. Leah Nagle Ombudsman

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