Not upheld: claim rejection / policy exclusion application complaint against Aviva Life & Pensions UK Limited

Decision detail

Summary

Mr and Mrs S complained that Aviva unfairly rejected Mr S's critical illness insurance claim for a non-invasive cancer diagnosis made in 2025 under a policy purchased in 2012. Aviva declined the claim based on a non-invasive cancer exclusion in the policy terms, which was supported by medical evidence. The ombudsman found the exclusion was standard in critical illness policies, in line with ABI guidance, clearly stated in the policy terms, and that Aviva acted fairly and reasonably in applying it. The complaint was not upheld, and the ombudsman noted that any concerns about policy suitability or sales information should be directed to the IFA who sold the policy.

The Ombudsman's reasoning

The ombudsman found that Aviva acted fairly and reasonably in declining the claim because: (1) the non-invasive cancer exclusion is standard in critical illness policies and in line with ABI guidance; (2) the exclusion is clearly stated in the policy terms; (3) the medical evidence confirmed Mr S's cancer was non-invasive; (4) insurers are entitled to set limits on the risks they accept; and (5) even if pre-contractual documentation could have been clearer, this would not have led Mr S to act to his detriment as no comparable policies on the market at the time would have covered non-invasive cancer.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website