Not upheld: unfair claims decline — misapplication of permanency criterion complaint against Aviva Life & Pensions UK Limited

Decision detail

Summary

Mrs S claimed total permanent disability benefit under her critical illness cover following a December 2024 diagnosis of rheumatoid arthritis. Aviva declined the claim, arguing that whilst RA is incurable, Mrs S's symptoms are not yet permanent as she remains early in her treatment pathway with further medication options available. The ombudsman upheld Aviva's decision, finding that the policy requires not only inability to perform activities of daily work but also that symptoms be permanent and irreversible. Since medical evidence showed further treatment (including biologic agents) could potentially achieve remission, the permanency criterion was not satisfied. The ombudsman noted Mrs S may have a valid future claim if her condition reaches a point where no further treatment is available and symptoms remain unimproved.

The Ombudsman's reasoning

The ombudsman found that whilst Mrs S has RA (which is incurable) and is unable to perform certain activities of daily work, the policy requires symptoms to be permanent and irreversible. The medical evidence demonstrates Mrs S is early in her treatment pathway with further treatment options available, including biologic agents. The specialist's opinion that remission could be achieved with continued treatment means the permanency criterion is not yet satisfied. The ombudsman noted this is not unusual for such claims and that permanency is only established when no further treatment is available and specialists agree nothing more can be offered.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website