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Jo C.
Jo C., Barrister
Category: Law
Satisfied Customers: 71053
Experience:  Over 5 years in practice
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My wife and I are insured with AXA PPP for both medical and

Customer Question

My wife and I are insured with AXA PPP for both medical and travel costs. We had a boating accident abroad. My wife was seriously injured and was operated on is the US. AXA PPP covered these costs, however insisted that all further treatment for my wife should be carried out in the UK. Our medical cover in the UK does not cover consultations and tests. My wife cannot continue her treatment in the US, as mentioned, and therefore has had to be examined by the UK consultants as a new case, which according to AXA PPP is not covered because our medical insurance does not cover consultations. Sort of a "Catch 22" situation. Example: my wife will have an operation next week to repair/replace a tear duct to her left eye; PPP AXA has authorised payment for the operation, anaethetist, and hospital, however has refused to pay for the consultation and tests by the surgeon involved. My position is that they should, because if the operation had been carried out in the US no consultant fees would be involved as the same surgical team would have carried out the procedure mentioned above.
Submitted: 4 years ago.
Category: Law
Expert:  Jo C. replied 4 years ago.

Thank you for your question. My name is Jo and I will try to help with this.

What would you like to know about this please?
Customer: replied 4 years ago.

I would like to know what recourse I have to compel AXA PPP to pay consultation/tests costs. Their stance is: Your travel policy with AXAPPP covers only expenses incurred abroad as a result of the injury; any further treatment necessary as a result of said injury must be done in the UK under the terms of your UK medical policy with AXAPPP which does not cover consultations/tests. The problem is that the specialists in the UK that are now treating my wife must of necessity have a preliminary consultation, and, if they deem it necessary, carry out tests, despite the fact that they have copies of all the records for the operation she had abroad. AXAPPP offered us insurance for both travel and medical, under separate policies, and now say that as treatment is to be carried out in the UK - at their request, we must conform to the the terms of the UK policy, which does not cover consultation,etc.

Expert:  Jo C. replied 4 years ago.

I assume that you have now returned from the States?

Unless these costs are specifically excluded from the policy then the insurance company is not liable to pay them.

However, I would not give up that easily.

If they steadfastly refuse to pay for these costs it is not a matter that I would take to court because this could really go either way and depending on the cost involved, it might not be Small Claims Court sum.

If it were not a Small Claims Court sum and you lost your case then you could face many thousands of pounds of legal costs.

What you can do, which is free but slow is make a formal complaint to the insurance company and if they will still not pay up, refer the matter to the Financial Ombudsman.

The Financial Ombudsman is not quick but will look at the policy and the circumstances and decide one way or the other.

It could take 12 months to resolve but at least it is risk-free.

Can I clarify anything for you?