Not upheld: claim declined - pre-existing condition exclusion complaint against Aviva Insurance Limited

Decision detail

Summary

Mr C claimed on his private medical insurance policy for extraction of his lower left wisdom tooth in March 2025. Aviva declined the claim on the basis that the condition was pre-existing, as the policy was taken out on a moratorium basis in June 2023 excluding conditions present in the five years prior. The ombudsman examined dental records from November 2022 and subsequent visits which consistently referenced lower wisdom teeth in plural and discussed treatment options for both teeth. Although Mr C argued the left tooth was not discussed and was completely buried under the gum at that time, the clinical records did not support this assertion. The ombudsman found Aviva reasonably concluded the symptoms were pre-existing and upheld the claim declination.

The Ombudsman's reasoning

The ombudsman found that clinical records are the best source of evidence and it was reasonable for Aviva to rely on them. The dental records from November 2022 and subsequent visits consistently reference lower wisdom teeth in plural, indicating Mr C was experiencing hygiene issues with both lower wisdom teeth prior to the June 2023 policy inception. Although Mr C disputed this interpretation, he provided no corroborating evidence that the dentist and hygienist made errors in using the plural. The dentist's subsequent letter and correspondence did not definitively confirm the absence of issues with the lower left tooth. Therefore, Aviva reasonably concluded the symptoms were pre-existing and covered by the moratorium exclusion.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website