Not upheld: claim rejection - critical illness insurance complaint against Aviva Life & Pensions UK Limited

Decision detail

Summary

Mr C claimed on two critical illness insurance policies underwritten by Aviva for a cancer diagnosis from several years prior. Aviva declined both claims on the basis that the cancer was non-invasive and therefore not covered under the policy definitions, which explicitly exclude non-invasive cancers. Mr C subsequently provided a new medical report from a consultant surgeon suggesting potential disease progression, but the report did not state the cancer was histologically invasive. The ombudsman found the medical evidence and expert commentary provided by Aviva more persuasive and concluded that Aviva acted fairly and reasonably in declining the claims in accordance with the clear policy terms and industry best practice standards.

The Ombudsman's reasoning

The ombudsman applied industry rules requiring fair claims handling and considered the applicable Association of British Insurers Statement of Best Practice. The ombudsman found that both policies contained clear definitions requiring invasive cancer for benefit payment and explicitly excluded non-invasive cancers. The medical evidence, including the expert commentary provided by Aviva, was more persuasive than Mr D's report in establishing that Mr C's cancer was histologically non-invasive and therefore did not meet the policy definition. The ombudsman concluded Aviva did not act unfairly or unreasonably in declining the claims based on the clear policy terms and persuasive medical evidence.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website