Not upheld: claim denial / coverage exclusion for chronic condition complaint against Aviva Insurance Limited

Decision detail

Summary

Mr M complained that Aviva Insurance Limited unreasonably declined to pay for a diagnostic injection to his AC joint as part of treatment for a shoulder injury sustained in early 2023. Aviva classified the injection as pain management for a chronic condition, which was excluded from coverage under the policy. The ombudsman found that while the initial injury was an acute condition, it had become chronic by the time the injection was recommended in early 2025, approximately two years later. The condition exhibited characteristics of chronic conditions including ongoing monitoring needs, symptom relief requirements, and no known cure. The ombudsman upheld Aviva's decision to decline the claim as it was consistent with the policy terms.

The Ombudsman's reasoning

The ombudsman found that while the initial shoulder injury was an acute condition, it had become a chronic condition by the time the disputed AC joint injection was recommended. The key factors were: the injection was recommended approximately two years after the injury; the condition no longer met the policy definition of acute (which requires quick response to treatment); and the condition exhibited characteristics of chronic conditions including ongoing monitoring needs, symptom relief requirements, indefinite continuation, and no known cure. Although the treating surgeon labelled the injection 'diagnostic', they did not explain what it would diagnose or how it would affect treatment decisions, and Mr M's explanation of its diagnostic purpose was not corroborated by the surgeon.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website