Not upheld: claim decline - total and permanent disability (TPD) assessment complaint against Aviva Life & Pensions UK Limited

Decision detail

Summary

Mr and Mrs C complained that Aviva unfairly declined Mrs C's total and permanent disability (TPD) claim following her diagnosis of complex PTSD and related mental health conditions, arguing her symptoms were so severe she was medically retired and incapable of future work. Aviva declined the claim because Mrs C did not meet the policy requirement of being unable to perform three of seven defined activities of daily work on a permanent basis. The ombudsman reviewed the medical evidence and found it did not persuasively demonstrate permanent inability to complete three activities, noting that while Mrs C had some difficulties with walking (when outside), communication, and healthcare management, these did not meet the policy's strict criteria, and her treatment pathway remained active. The ombudsman upheld Aviva's decision as fair and reasonable, though noted that circumstances could change if Mrs C's condition progressed.

The Ombudsman's reasoning

The ombudsman applied the policy terms requiring Mrs C to be unable to perform three of seven activities of daily work on a permanent and irreversible basis. While acknowledging Mrs C's severe symptoms and difficult circumstances, the ombudsman found the medical evidence did not persuasively demonstrate permanent inability to complete three activities. Specifically: walking difficulties were limited to when outside (not meeting the policy's absolute standard); no evidence of climbing, bending, or eyesight difficulties; some evidence of communication and healthcare management issues but insufficient to meet three-activity threshold; and financial independence was a preference rather than medical necessity. The ombudsman noted Mrs C's treatment pathway remained active, suggesting permanency had not been established. The ombudsman also found Aviva's claim form delays were reasonable given the need to source correct policy terms.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website