DRN-6104331

The complaint Mr L is unhappy about the way AXA PPP Healthcare Limited handled a claim made on a group private health insurance policy he benefits from (‘the 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 all points made by Mr L along with all other evidence. I won’t respond to each of these. I hope he understands 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. In considering what is fair and reasonable in all the circumstances of the case, I’ve taken into account all relevant law and regulations, regulator’s rules, guidance and standards, codes of practice and good industry practice at the relevant time. This includes AXA’s obligation to handle insurance claims fairly and promptly. And to not unreasonably decline a claim. I know Mr L feels very strongly that AXA hasn’t acted fairly and reasonably by not covering more medical costs relating to fertility treatment. I’m sorry to disappoint him but, for reasons I’ve set out below, I’m satisfied AXA doesn’t have to pay for any further medical costs claimed. Subject to the remaining terms of the policy, cover is provided for infertility and assisted reproduction. It says: …if you decide to have treatment privately, we pay for investigations and treatment up to £15,000 per lifetime membership, when your GP refers you… The treatment we pay for includes: • Assisted reproduction… • Any treatment you need, as a result of these treatment or investigations… • Transportation of tissue when this is part of a current cycle of fertility treatment and is part of the costs invoiced by your UK clinical provider

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• Cryopreservation, storage or thawing of egg, ovary, testicular tissue or embryos when this is part of a current cycle of fertility treatment • Drugs when they are prescribed by a specialist as part of the conventional treatment The policy defines ‘you/your’ as: The lead member and any family members covered by the plan. Mr L’s wife isn’t named as a family member covered by the policy. AXA did cover the cost of semen analysis as it related to Mr L. However, it said other costs related to treatment, tests and medication for Mr L’s wife, so declined cover for those costs. I’m satisfied that AXA has fairly declined costs relating to medication Mrs L received as part of the overall fertility treatment. She isn’t named as a beneficiary of the policy, and they were administered to her. I’ve thought very carefully about whether the costs relating to “TFP Freeze all and transfer cycle” should be covered. There are two invoices in respect of this (over £6,500 each). Mr L says that the “freeze all” is a descriptor of how the cycle works. And that eggs are collected, fertilised and embryos allowed to develop until they are biopsied and sent for testing. Those embryos must then be frozen whilst testing takes place. Healthy embryos are thawed as soon as test results come back and transferred to the (female) patient around a month later. AXA has concluded that this treatment relates to Mr Ls’ wife and so isn’t covered under the policy. I’m satisfied that its conclusion is fair and reasonable. When making this finding, I’ve taken into account what Mr L says about the GP referral reflecting that Mr L had a history of unexplained infertility (which led to the IVF treatment), IVF treatment involving both the male and female and the majority of costs relating to embryology (culturing the embryo in a laboratory until its transfer to the female and that this relates equally to the male as it does the female). Mr L feels AXA has acted in a discriminatory way (on the grounds of sex). When considering whether AXA acted fairly and reasonably, I’m required to take into account relevant law such as the Equality Act 2010. However, I have no power to make a finding about whether a business has acted unlawfully. Only a court can do that. I’m not persuaded that Mr L’s sex played a part in AXA’s decision to decline the majority of costs claimed in relation to fertility treatment. I’m satisfied the costs which were declined related to treatment for his wife, and she wasn’t insured under the policy. I wouldn’t ordinarily expect an insurer to cover costs for someone not insured under the policy. AXA has said that if Mr L’s wife had been insured under the policy and Mr L hadn’t been, it wouldn’t have covered the semen analysis. That’s because it related to Mr L and not his wife. I’m satisfied that’s the case as I have no compelling evidence to doubt what AXA has said. The medical evidence does support that it was Mr L’s infertility which led to he and his wife accessing fertility treatment. However, I’m not persuaded that means certain costs for infertility (as they relate to his wife) should be covered outside of the policy terms.

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I’ve also considered what Mr L says that it should be made clearer in the policy terms that male members aren’t eligible for fertility treatment and that the terms are unfair and misleading about the cover available. However, I’m satisfied that a male beneficiary can still benefit from fertility cover under the policy (which Mr L did as the cost relating to semen analysis was covered). It’s also made reasonably clear that the policy only provides cover for those who are beneficiaries of the policy. I’ve also taken into account that a particular (relevant) authority in the context of IVF treatment says it would “generally consider ‘patient’ to encompass both the woman and her partner (where applicable) seeking treatment and this is reflected in the patient information that we publish on our…website and in the guidance, we provide to fertility clinics”. That may be the case, however, in the circumstances here, I’m more persuaded by how the policy terms define ‘you’. And as Mr L’s wife wasn’t a beneficiary of the policy, I don’t think AXA has unfairly declined covering costs which relate to her treatment – including the “TFP Freeze all and transfer cycle”. Finally, I’ve also considered that AXA initially declined the claim for “TFP Freeze all and transfer cycle” as it had understood that the cryopreservation, storage or thawing of egg / embryos wasn’t part of the current cycle of fertility treatment. When Mr L clarified that it was in connection with the current cycle of fertility treatment, AXA promptly corrected its misunderstanding and declined these costs as they related to his wife, who was not covered under the policy. So, I’m satisfied that there was no impact to Mr L of the costs being initially declined for an incorrect reason. I’m satisfied the error was promptly rectified and the costs fairly declined for a different reason. My final decision I don’t uphold Mr L’s complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr L to accept or reject my decision before 12 May 2026. David Curtis-Johnson Ombudsman

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