Not upheld: claim declined - policy exclusion applied complaint against Aviva Insurance Limited

Decision detail

Summary

Ms P claimed on her group private medical insurance policy for surgical removal of an IUD that had become embedded during an attempted removal procedure. Aviva declined the claim citing a policy exclusion for anything related to birth control, as the IUD was originally inserted in 2011 for contraceptive purposes. Although Ms P was seeking removal to have a Mirena coil fitted for menopause support, the ombudsman found that Aviva fairly applied the exclusion since the complications arose directly from a device fitted for contraceptive purposes. The ombudsman rejected Ms P's argument that the exclusion should not apply to surgical treatment for an embedded device, finding the exclusion sufficiently clear and a legitimate commercial decision.

The Ombudsman's reasoning

The ombudsman found that Aviva's birth control exclusion was sufficiently clear and applied fairly. The exclusion covers anything 'directly or indirectly arising from or in connection with' birth control. Since the IUD was fitted for contraceptive purposes in 2011, the complications requiring surgical removal fell within this exclusion, regardless of the subsequent reason for removal (menopause treatment). The fact that the treatment was unforeseen does not override the contractual exclusion, which is a commercial decision Aviva is entitled to make. The provision of cover for the diagnostic scan does not obligate Aviva to cover treatment for conditions identified within it.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website