Not upheld: claim rejection — application of pre-existing condition exclusion under moratorium clause complaint against Aviva Insurance Limited
Financial Ombudsman decision DRN-6247914 of 2026-05-14T00:00:00+00:00. claim rejection — application of pre-existing condition exclusion under moratorium clause complaint against Aviva Insurance Limited. Outcome: Not upheld.
Decision detail
| Reference | DRN-6247914 |
|---|---|
| Decision date | 2026-05-14T00:00:00+00:00 |
| Firm | Aviva Insurance Limited |
| Product | insurance — group private medical insurance |
| Claim type | claim rejection — application of pre-existing condition exclusion under moratorium clause |
| Outcome | Not upheld |
| Remedy | None. The complaint was not upheld. The ombudsman noted that if Mr H obtains new medical evidence showing the ultimate treatment was entirely separate and distinct from tonsillitis, he may submit this to Aviva for reconsideration. |
Summary
Mr H complained that Aviva Insurance Limited unfairly rejected a claim for his daughter Miss H's ENT treatment under a group private medical insurance policy. Miss H was referred to an ENT specialist in January 2025 for enlarged tonsils following bouts of tonsillitis in late 2024. Aviva turned down the claim, concluding the condition was pre-existing and excluded by the policy's moratorium clause. Medical records showed Miss H had experienced tonsillitis symptoms, received treatment and antibiotics, and had documented large tonsils dating back to 2020, within the five-year pre-existing condition lookback period. The ombudsman found Aviva fairly applied the moratorium clause based on the available medical evidence and did not uphold the complaint.
The Ombudsman's reasoning
The ombudsman concluded that Aviva fairly relied on the medical evidence to determine that Miss H's condition was pre-existing. The policy terms clearly exclude treatment for conditions where a member had symptoms, medication, diagnostic tests, treatment or advice in the five years before joining the policy. Miss H had documented evidence of tonsillitis symptoms and treatment dating back to 2020, within the five-year lookback period. The GP's referral specifically concerned enlarged tonsils, which were documented in Miss H's medical records during previous infections. Aviva's clinical team appropriately linked the previous symptoms to the current claim. The ombudsman found no medical evidence contradicting Aviva's conclusion at the time of assessment.
How this compares
| Group | Decisions | Uphold rate |
|---|---|---|
| Aviva Insurance Limited, all decisions | 5,081 | 27% |
Source
Read the original decision on the Financial Ombudsman Service website