AXA PPP Healthcare Claim Denied: How to Appeal Your UK PMI Decision

AXA PPP Healthcare Claim Denied: How to Appeal Your UK PMI Decision

AXA Health (formerly AXA PPP Healthcare) is one of the UK's largest private medical insurance (PMI) providers, serving over 3 million individual and corporate members. Part of the global AXA Group, AXA Health offers a range of personal and business private healthcare plans.

If AXA Health has denied your PMI claim — whether for consultant fees, hospital treatment, diagnostics, or mental health care — you have the right to challenge that decision through AXA Health's formal complaints process and, if necessary, through the Financial Ombudsman Service (FOS).

About AXA Health

AXA Health's UK products include:

• Personal health insurance (individual and family plans)
• Business health insurance (SME and corporate group schemes)
• Cash plans (fixed cash benefits for routine care)
• Dental insurance
• Mental health cover (including BestDoctors programme)
• Expatriate health insurance

AXA Health operates a network of approved hospitals and consultants. Treatment within the network receives the highest coverage level; treatment outside the network may result in reduced or no coverage.

Common AXA Health Denial Reasons

Pre-existing condition exclusions: The most common AXA Health denial. AXA Health uses either moratorium or full medical underwriting to establish what is and isn't covered:

• Moratorium: Conditions you had in the 5 years before taking out cover are excluded for the first 2 years of the policy. After 2 years without symptoms or treatment, the exclusion typically lifts.
• Full medical underwriting (FMU): AXA reviews your medical history at application and lists specific exclusions. These listed exclusions are permanent (unless you successfully apply for a review).

Common disputes: whether your current condition is "the same as" or "related to" a pre-existing condition; whether the moratorium period has genuinely elapsed without symptoms.

Not clinically appropriate/necessary: AXA Health may deny treatment that its clinical reviewers determine is not clinically appropriate — i.e., the requested treatment is not the most appropriate for your condition according to AXA's clinical criteria.

Out-of-network treatment: Treatment at a hospital or by a consultant not on AXA Health's approved list may not be covered or may be covered at a lower rate.

Chronic condition exclusions: AXA Health distinguishes between acute conditions (covered) and chronic conditions (typically limited or excluded). Disputes arise about whether a condition is acute or chronic under AXA's definitions.

Mental health and psychiatric treatment: Mental health cover limits (number of days/sessions) are a common source of disputes. AXA Health has expanded mental health cover in recent years, but limits remain and disputes arise.

Waiting periods: Some AXA Health plans have waiting periods for certain types of treatment. Claims made during the waiting period are denied.

Out-of-pocket costs: Disputes about what AXA Health will pay vs. what the consultant charges (particularly for consultants who charge above AXA's fee schedule).

Your UK Rights When AXA Health Denies a Claim

FCA regulation: AXA Health is regulated by the Financial Conduct Authority (FCA). FCA rules require AXA Health to handle complaints fairly and promptly.

Financial Ombudsman Service (FOS): After exhausting AXA Health's internal complaints process, you can refer your complaint to the FOS for a free, independent review. FOS decisions are binding on AXA Health.

ABI Code of Practice: The Association of British Insurers' code provides industry standards for claims handling.

Step-by-Step: How to Appeal an AXA Health Denial

Step 1: Understand AXA Health's Denial

Review AXA Health's written denial carefully:

• What exactly is being denied (the treatment, the consultant, the facility)?
• What reason is given (pre-existing condition, not clinically appropriate, out-of-network)?
• What specific policy clause is cited?

Request this in writing if you were told verbally.

Step 2: Contact AXA Health's Clinical Review Team

AXA Health has a clinical review team that reviews pre-authorisation and coverage decisions. Before filing a formal complaint, ask to speak with a clinical reviewer or ask your consultant to liaise with AXA Health directly about the clinical basis for the denial. Sometimes consultants have established channels with insurers' clinical teams and can resolve issues directly.

Step 3: Gather Supporting Evidence

For pre-existing condition disputes:

• GP letter confirming timeline of symptoms and diagnoses
• Evidence that you had no symptoms during the moratorium period (GP records confirming no consultations or treatment)
• Your treating specialist's opinion on whether your current condition is related to any prior condition

For clinical appropriateness disputes:

• Your consultant's detailed letter explaining why this specific treatment, at this specific facility, is clinically appropriate for your condition
• Clinical guidelines from professional bodies (NICE, relevant Royal Colleges) supporting the treatment
• Second consultant opinion (from an AXA-approved consultant) if available

For chronic/acute disputes:

• Your specialist's explanation of why the condition is acute (the current episode is new, not a continuation of a pre-existing chronic condition)

Step 4: Submit a Formal Complaint to AXA Health

AXA Health Customer Relations:

• Phone: 0800 587 6144
• Online: axahealth.co.uk/contact
• Post: AXA Health, The Aquarius Centre, Tunbridge Wells, TN1 1SN

Mark your correspondence clearly as a formal complaint. Include:

• Policy number and membership number
• Claim number(s)
• Clear explanation of why the denial is incorrect
• All supporting medical documentation
• Requested outcome

AXA Health must:

• Acknowledge within 5 business days
• Provide a Final Response within 8 weeks

Step 5: Request a Medical Reviewer (If Applicable)

For clinical appropriateness disputes, ask AXA Health to refer your case to an independent medical reviewer. Some PMI disputes can be resolved through clinical peer review rather than formal complaints.

Step 6: Escalate to the Financial Ombudsman Service

After AXA Health's Final Response (or after 8 weeks without a response):

FOS Contact:

• Online: financial-ombudsman.org.uk
• Phone: 0800 023 4567
• Deadline: Within 6 months of AXA Health's Final Response

The FOS is particularly effective for:

• Pre-existing condition exclusion disputes (FOS applies a fairness test to whether AXA applied the exclusion correctly)
• Moratorium disputes (FOS examines whether AXA correctly assessed symptom timelines)
• Mental health coverage disputes

AXA Health-Specific Tips

Pre-authorisation: Always call AXA Health for pre-authorisation before elective treatment. Failure to pre-authorise gives AXA grounds to deny that are difficult to overcome.

Mental health: AXA Health's mental health cover has improved significantly in recent years. If you are denied mental health treatment, check whether AXA Health's BestDoctors or mental health pathway programmes might cover your needs.

Consultant fees: If your consultant charges above AXA Health's fee schedule, AXA Health will only pay up to its schedule amount. The difference is billed to you. Check with your consultant before treatment whether they will accept AXA Health's fee schedule.

Second opinion: AXA Health's policy typically covers a second medical opinion from an approved specialist. If your treatment is denied, use this benefit to obtain independent clinical confirmation of your need.

Overseas treatment: AXA Health's standard UK plans typically do not cover treatment abroad. Check your plan if you are considering treatment overseas.

Conclusion

AXA Health (formerly AXA PPP Healthcare) is a major UK PMI provider, but their denials — particularly pre-existing condition exclusions — are frequently successfully challenged. The Financial Ombudsman Service provides a free, independent, and effective route to challenge AXA Health decisions that you believe are incorrect. Don't accept a denial without pursuing all available remedies. Use ClaimBack at claimback.app to generate a professional complaint letter for your AXA Health insurance dispute.

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