AXA Healthcare Limited · DRN-6225537

The complaint Mrs K and Mr R complain AXA Healthcare Limited mis-sold them a private medical insurance policy. Mr R brings the complaint on behalf of himself and Mrs K, so for ease I will refer to all submissions as having been made by Mr R. What happened Mr R took out a private medical insurance policy over the phone in October 2021. The cover is underwritten by AXA. In 2024, Mr R became seriously unwell and required treatment, which he underwent at a hospital which I will call ‘hospital M’. AXA said only 60% of the treatment costs would be covered, as although the specialist was covered under the policy, hospital M was not one on the approved list for the level of cover Mr R held. Mr R complained to AXA that his policy had been mis-sold. The insurer responded and said it thought it had provided sufficient information and had not done anything wrong. Unhappy with the response, Mr R brought his complaint to this service and the case was passed to me to decide. I didn’t think AXA had mis-sold the policy, so I issued a provisional decision to both parties. My provisional decision “In view of Mr R’s concerns about having sought out an AXA brand policy, but receiving a call from an employee of health-on-line, I asked AXA for some more information about the initial sales process. AXA has shown evidence that it received a referral to contact Mr R about his interest in an insurance policy via a third party. It said Mr R had submitted his interest in an insurance quote via a third party website, who passed it on to AXA. And AXA then arranged for one of its agents to call Mr R. AXA explained that health-on-line is part of AXA health and that the agent who called Mr R was able to sell both AXA brand and health-on-line brand policies. AXA said it gave Mr R three cover options in terms of hospitals he could use. Option 1 – ‘full list’ - approximately 300 hospitals Option 2 – ‘standard list’ - approximately 120 hospitals Option 3 – ‘lower cost list’ - approximately 60 hospitals

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AXA said if Mr R had chosen Option 1 or Option 3, this would have resulted in him being sold a policy which was branded ‘AXA’. However he chose Option 2, which resulted in him being sold a policy branded ‘health-on-line’. And AXA has also confirmed there was no commission or incentive for its agent to sell one brand over another. Mr R took out his policy over the phone with a representative of AXA. This was not an advised sale – this means AXA wasn’t responsible for ensuring the policy was suitable for Mr R’s needs. However, it was obliged to provide sufficient information about the cover to enable Mr R to make an informed decision about whether to take it out. Mr R says he wanted a policy which was branded ‘AXA’ but the policy he received was branded ‘health-on-line’ and he says the agent who sold him the policy was deceptive. I’ve reviewed recordings of two sales calls from 2021. In the first call the agent advised Mr R they were calling from ‘AXA Health’ and within the first couple of minutes read out a statement which confirmed ‘AXA Health’ is a trading name of ‘health-on-line company’ and they said the policies were underwritten by AXA. The agent asked Mr R various questions about the cover he was looking for. He elected to take the ‘Comprehensive Cancer Cover’ offered. Mr R has said he wanted the ‘top level’ of cancer cover, and believed he had this on his policy. But he’s said the policy has not provided this, as hospital M was not fully covered when he needed cancer treatment. I’ve gone on to review the policy terms around cancer cover. The policy states that there are two levels of cancer cover available. They are ‘Comprehensive Cancer Cover’ and ‘NHS Cancer support’. Mr R’s policy schedule shows he had the ‘Comprehensive Cancer Cover’ which is the higher level of the two types of cover. The policy explains what the cancer cover includes in terms of diagnostics, surgery, therapies and monitoring and includes many benefits not available with the lower level of cover (NHS Cancer support). And it states the place of treatment to be hospitals “listed in the hospital list”. The policy certificate also stated that the full costs of treatment in hospitals not on the hospital list, were not covered. So, based on the above, I’m satisfied Mr R’s policy included the top level of cancer cover he asked for. And I’m satisfied the hospital list applied to cancer treatment, as this is stated in the policy terms. Regarding hospitals Mr R could use if he needed treatment, the agent advised there were three options to choose from. The first was the ‘full list’ and they said this would give “access to around 300 hospitals nationwide”. And they said this level of cover can be “more expensive as it does include some of the top leading London flagship hospitals” and they gave examples including naming hospital M as being on the list. They then went on to explain another option – the ‘standard list’ and said this “gives you access to around 120 hospitals nationwide” and gave examples of two hospital group names. And they went on to explain the third option – the ‘lower cost list’. Mr R has said he doesn’t understand why the agent didn’t ‘sell’ the better hospital list to him. And he said he asked what would happen if a hospital in his area was unable to treat him, but this went unanswered.

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I’ve listened carefully to this part of the call. Mr R mentioned some private hospitals which I will refer to as the ‘S hospitals’. The agent confirmed those hospitals were on all three of the lists. Mr R said he was unsure if depending on the condition he might be referred to a different hospital in the UK. In answer to this the agent said “entirely up to you”. She listed the S hospitals near to Mr R and said these were on all three lists. She then went on to say “If - and I don’t know your budget – if cost is you know, it’s up to you […] if you want to look at two of the different lists or three of the different lists, you tell me.” And she went on to give an example of the closest S hospitals to Mr R on the ‘standard list’ and told him the name of the next closest hospital 30 miles away. Mr R said he didn’t know which to choose and asked “If [S hospital] can’t cater for something what would normally happen – you’d go further afield?”. And the agent answered ‘yes’. And Mr R then chose the middle option – the standard list. I’m satisfied the agent presented each hospital option neutrally, which is what I would expect in the circumstances of a non-advised sale. She set out the options and asked Mr R which was his preference and I don’t think she led him to any of the options. There were several mentions of the ‘S hospitals’ by the agent, but I think this was reasonable as Mr R had set out that he was aware of these hospitals being in the area where he lived. I’ve also listened to the second call which took place after Mr R had received the quotes. He asked various questions about cover which could be added and removed and the difference this would make to the price, but there was no discussion about changing the option he had chosen for the hospital lists. After Mr R confirmed he wanted to go ahead, the agent went through what was included in the cover he’d chosen. As part of this they said that if a hospital is used that is not within the network, AXA would only pay 60% of the hospital charges. I accept that Mr R would have been offered either an AXA brand or a health-on-line brand policy depending on the cover choices he made. And I’m satisfied the hospital list options were clearly explained to Mr R, and that he chose to take option 2, which was the ‘standard list’, rather than option 1 which was the ‘full list’ which included hospital M. I know Mr R feels very strongly that he should have been told about the differences between AXA brand and health-on-line brand policies. I’ve thought about this, however I haven’t seen that this was something Mr R asked about during the sales process. Rather AXA asked Mr R a series of questions about his needs for cover, and provided him with quotes based on the choices he made. I think that’s reasonable and what I would expect an insurer to do. And I’m satisfied AXA presented the different levels of hospital cover available clearly, so Mr R was given sufficient information to make his choice. AXA has been unable to send me copies of the quotation emails it sent to Mr R, but it has given me copies of the ‘welcome’ email and policy booklet sent in October 2021. I’m satisfied that these documents are clearly and prominently branded ‘health-on- line’ so I think this would be the point at which I would have expected Mr R to have raised a query or concern, if he’d only wanted an AXA brand policy and was unhappy to have taken out a ‘health-on-line’ brand policy. And at the time he had the option to cancel the policy within the 14 day cooling off period. However I’ve not seen evidence that Mr R raised concerns about the policy being brand ‘health-on-line’ until 2024. Overall, having reviewed the sales journey, I’m not persuaded AXA mis-sold the policy to Mr R. I’m satisfied that the brand and type of policy Mr R received was

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directly related to the level of cover he selected in terms of hospitals he wanted to be able to use. And that the options were clearly offered and explained to him. And I’m satisfied he asked for and received the highest level of cancer cover AXA had available. I’ve also considered whether it was fair for AXA to pay only 60% of the costs of the treatment Mr R received at hospital M. After Mr R took out the policy, he was sent the policy terms and conditions. On page 2 there is information about the importance of using hospitals on the hospital list. And it’s stated that if treatment is undertaken at a hospital not on the list, AXA will only pay 60% of the charges and the policyholder will be responsible for the remainder. There’s also a statement in bold on this page which says “Not all specialists and specialities are available at all private hospitals.” And so I’m satisfied AXA was not required to pay more than 60% of the costs for treatment at hospital M, as this is in line with the policy terms for a hospital not on the hospital list. Mr R has queried why the policy refers to ‘hospital list’ in a singular form, if there are multiple hospital lists. Mr R was offered three different hospital list options at the point of sale. However once he had chosen and taken out his policy, only one list applied to his cover, so I think it reasonable that the insurer only referred to this. The policy booklet refers to ‘the hospital list’ and the policy schedule confirms Mr R had access to 140 private hospitals and gave a website link to the list. I’m very sorry to hear of the serious illness Mr R has been through and understand the reasons he had treatment at hospital M. I know my decision will likely come as a disappointment to him, however, I haven’t found that AXA has acted unfairly or unreasonably in this case.” The response to my provisional decision Mr R responded to the provisional decision. In summary he said he still thought AXA hadn’t been honest when selling the policy. He said AXA had used its brand name to sell him a less comprehensive policy, without being truthful about the differences between AXA and health- on-line. He said he thought health-on-line was the name of AXA’s customer portal, and had he been told of the differences between the brands, he wouldn’t have taken out the health- on-line policy. 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. And I've considered again my provisional findings in light of Mr R’s response. Whilst I appreciate Mr R’s strength of feeling about the brand of his policy, I’m still not persuaded AXA mis-sold the cover. I say this because the type of policy sold was determined by the cover choices Mr R made, and I saw no evidence that he asked AXA about the difference between the brands, or queried why his policy was branded ‘health-on- line’ and not ‘AXA’ when he received the documents. I’ve noted Mr R’s comments that he thought ‘health-on-line’ was simply the name of a customer portal. But I can’t fairly say this

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misunderstanding was caused by the insurer, as I found the policy documentation to have been clearly and prominently branded. The points Mr R raised haven’t changed my mind. So I see no reason to depart from the conclusions set out in my provisional decision and summarised above. My final decision For the reasons I’ve given, it’s my final decision that I do not uphold this complaint and I make no award against AXA Healthcare Limited. Under the rules of the Financial Ombudsman Service, I’m required to ask Mrs K and Mr R to accept or reject my decision before 14 April 2026. Gemma Warner Ombudsman

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