AXA PPP Healthcare Limited · DRN-6166368

The complaint Miss W is unhappy with the way AXA PPP Healthcare Limited (‘AXA’) has dealt with her claim for mental health treatment under a group private medical insurance policy she benefits from (‘the policy’). What happened Miss W contacted AXA to access treatment for mental health under the policy. She was then referred to the third-party provider used by AXA to carry out an assessment and the options provided included for Miss M to have an appointment with a mental health specialist. Miss W is unhappy: • that AXA has deducted the cost of the cognitive behavioural therapy (‘CBT’) she’s been having from the outpatient benefit allowance, and applied an excess. She says the policy terms don’t clearly distinguish between counselling (the cost of which isn’t deducted from the outpatient benefit) and other forms of mental health treatment. • with the service received from AXA, in particular the way a call was handled on 14 January 2025. • that she can’t track how much of the outpatient benefit she’s used and that if she continued with CBT, she would need to pay more for each session than she would have done if she’d found a therapist and self-funded. Our investigator upheld Miss W’s complaint. AXA disagreed and raised points in reply. These didn’t change our investigator’s opinion. So, this complaint was passed to consider everything afresh. I issued my provisional decision explaining why I was intending to depart from our investigator’s recommendations. An extract of my provisional decision is set out below. ………………………………………………. I’ve considered all the available evidence and arguments to decide what’s fair and reasonable in the circumstances of this complaint. That includes all points made by the parties (along with all the other evidence). However, I won’t respond to each of these. I hope they understand that no discourtesy is intended by this. Instead, I’ve focussed on what I think are the key issues here. The rules that govern the Financial Ombudsman Service allow me to do this as we are an informal dispute resolution service. If there’s something I’ve not mentioned, it isn’t because I’ve overlooked it. I haven’t. I’m satisfied I don’t need to comment on every point to fulfil my statutory remit.

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AXA has an obligation to handle insurance claims fairly and promptly. The policy terms confirm that the policy provides cover for mental health treatment. In line with the policy terms, Miss W contacted AXA to check cover and was then referred to a third- party provider to carry out a mental health assessment to consider the treatment right for her. The policy terms reflect that: • Miss W has an outpatient limit of £1,500 each year and a £200 excess. • Mental health treatment by psychologists and psychotherapists are paid from the outpatient limit; and • Counselling sessions through its mental health assessments and support service aren’t subject to the policy excess or the outpatient limit. I have a lot of empathy for Miss W’s situation. I know she feels very strongly that AXA has acted unfairly here. However, for reasons I’ll go on to explain, I’m currently satisfied that AXA has acted fairly and reasonably by relying on the policy terms by deducting the cost of the CBT sessions she had from the outpatient benefit limit and apply an excess. • During the initial call between AXA and Miss W, AXA’s representative said they weren’t medically trained but explained some of the differences between counselling (‘short term’ and ‘follows your lead’) and other types of talking therapy (‘longer-term’ and ‘taking the therapist’s lead’). They said an assessment would be booked with its third-party provider and it would be for the third-party provider to decide the best course of action. • The call recording does cut out in places, but it also reflects that Miss W was told the cost of a CBT per session. So, from the parts of the call I can hear, I think it was made reasonably clear that the cost of CBT sessions would be deducted from the outpatient benefit allowance. I think that’s also consistent with the claim statements Miss W subsequently received from AXA, detailing the amount charged for CBT by the third-party provider. • Miss W has said that the third-party provider said she needed to access therapy quickly and to prevent any delay, she wasn’t referred to a psychiatrist or psychotherapist first for an initial assessment. She was referred directly for CBT. She says she was unaware that this didn’t constitute counselling under the policy terms. • I don’t know what information Miss W was provided by the third-party provider. I can only consider complaints about activities regulated by the Financial Conduct Authority. That includes where a regulated business (in this case AXA) is carrying out contracts of insurance. I’m satisfied that the third-party provider is independent from AXA and that AXA fulfilled its initial obligations by providing Miss W access to the mental health benefit under the policy, allowing the independent third-party provider to carry out its assessment. AXA also approved treatment. • I’m satisfied that CBT is different to counselling. Although, the policy terms don’t define counselling, I’m satisfied that during the initial call Miss W had with AXA she was clearly told that the outpatient benefit allowance doesn’t apply to counselling, but

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it does apply to other talking therapy. • Further, and in the alternative, even if AXA should’ve given Miss W clearer information about CBT not constituting counselling under the policy terms, on the balance of probabilities, I think it’s likely that she would’ve still gone ahead with CBT. That was the recommended treatment for her. I don’t think she would’ve gone against the advice and opted to access counselling instead. Whilst, I can’t say for sure, I also think it’s more likely than not, that Miss W would’ve accessed CBT through her policy rather than self-funding this at the time. Other issues AXA has explained in its final response dated 27 February 2025 that: We do not provide a live function to track your remaining allowances, and your benefit statements may not reflect the actual amount available. This is due to the possibility that we have not yet received or processed all bills from your providers or specialists. Therefore, it’s important for you to keep track of your attended sessions and remaining outpatient allowance. I don’t think that’s unfair in principle. I’m not persuaded that AXA is under any obligation to offer a live function to track remaining allowances. From what I’ve seen Miss W was sent claims’ statements setting out the cost of each session, the amount it paid, and what, if anything, Miss W was required to pay. I think that’s reasonable. If, at any time, Miss W wanted to check how much of the benefit remained available, she would’ve been free to contact AXA to check the invoices received and how much it had paid. Miss W is also unhappy about the amount AXA is charged for each CBT session by the third-party provider. However, I’m satisfied that it’s a commercial decision for AXA to decide how it structures its business model, and to agree the relevant rates with medical providers and it’s paying the invoices as billed. In its other final response dated 26 February 2025, AXA agreed that its representative should’ve better handled a call with Miss W on 14 January 2025. AXA accepts that the tone of the representative wasn’t acceptable and he should’ve provided Miss W with the customer relations email address and phone number when requested. It apologised, said feedback had been given and paid £50 compensation to Miss W. The call is uncomfortable to listen to. I don’t think £50 fairly reflects the impact of the call on Miss W. I accept this would’ve been very upsetting for Miss W, particularly as she was vulnerable and accessing mental health treatment. She was also put to the unnecessary trouble of having to raise her concerns through the portal. This would’ve been avoided if AXA’s representative had agreed to accurately record her concerns and relay these back to her. I’m satisfied that AXA should pay Miss W total compensation in the sum of £100 for distress and inconvenience. ………………………………………………… I invited both parties to provide any further information in response to my provisional decision. AXA replied, accepting my provisional decision. Miss W replied, disagreeing. In summary she said:

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• The policy doesn’t define or explain talking therapies, “counselling” or “CBT”. The NHS website defines both counselling and CBT as talking therapy. • It would be reasonable to interpret the policy wording in her favour so that the cost of the treatment she had wouldn’t be deducted from her outpatient allowance. Where there’s ambiguity, the policy term should be interpreted in her favour. • AXA didn’t make her aware of the type of treatment she’d be receiving. There was no follow up in writing. • She was vulnerable and in severe poor mental health at the time. • She would’ve sourced therapy through a different avenue if she’d known that CBT was coming from her outpatient allowance. And that a large proportion of the fees incurred related to administration fees by the third party. • She was told by the third party that she wasn’t being referred to a psychologist or psychiatrist for diagnosis / treatment as this would delay things too long. 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 all points made by Miss W in response to my provisional decision, which I’d considered when making my provisional decision. I appreciate that Miss W was vulnerable when seeking to access mental health treatment under the policy. I want to assure Miss W that I did take this into account when provisionally deciding her complaint against AXA. For reasons set out in my provisional decision, and from what I could hear, I think it was made reasonably clear to Miss W during her initial call with AXA the separate cost of CBT sessions and that the cost of talking therapy would be deducted from the outpatient benefit allowance. I don’t know what information Miss W was provided by the third-party provider. However, I’m satisfied that the third-party provider is independent from AXA so, that’s not something I’ve considered. AXA fulfilled its initial obligations by providing Miss W with access to the mental health benefit under the policy, allowing the independent third-party provider to carry out its assessment. AXA also approved (and, ultimately, covered) treatment in line with the terms of the policy. I appreciate that Miss W says that if she’d been given clearer information about what constituted counselling under the policy and what didn’t (impacting her outpatient allowance), she would’ve explored other options to access the treatment she needed. That’s, of course, entirely possible. However, I’ve considered what’s likely to have happened on the balance of probabilities. Even if AXA should’ve given Miss W clearer information about CBT not constituting counselling under the policy terms, I think it’s likely that Miss W would’ve still gone ahead with CBT via the third party. Miss W says that the third party recommended that she access urgent mental health treatment. And I don’t think she would’ve gone against the advice and opted to access counselling instead. Nor am I persuaded that she’d potentially risk delaying access to the treatment she needed to explore other avenues for CBT. For these reasons, and for reasons set out in my provisional decision (an extract of which is set out above and forms part of this final decision), I only partially uphold Miss W’s complaint.

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My final decision I partially uphold this complaint and direct AXA PPP Healthcare Limited to pay total compensation to Miss W in the sum of £100 for distress and inconvenience (less the £50 already offered if this has already been paid). Under the rules of the Financial Ombudsman Service, I’m required to ask Miss W to accept or reject my decision before 8 April 2026. David Curtis-Johnson Ombudsman

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