Upheld: unfair claims handling / claim wrongly declined complaint against Aviva Insurance Limited
Financial Ombudsman decision DRN-6249473 of 2026-05-28T00:00:00+00:00. unfair claims handling / claim wrongly declined complaint against Aviva Insurance Limited. Outcome: Upheld.
Decision detail
| Reference | DRN-6249473 |
|---|---|
| Decision date | 2026-05-28T00:00:00+00:00 |
| Firm | Aviva Insurance Limited |
| Product | legal expenses insurance |
| Claim type | unfair claims handling / claim wrongly declined |
| Outcome | Upheld |
| Remedy | Aviva must: (1) Fund the required expert medical report(s) and reassess whether the claim meets policy requirements; (2) Reimburse Mr S the cost of the Barrister's opinion plus 8% simple interest per year from the date of payment; (3) Pay Mr S £750 compensation. Payment must be made within 28 days, with additional 8% interest if paid late. |
Summary
Mr S, as executor of Mrs S' estate, complained that Aviva Insurance Limited unfairly declined a medical negligence legal expenses claim. Mrs S had sought to claim for delayed cancer diagnosis, and while Aviva's panel solicitors initially rejected it as lacking prospects of success, a Barrister's opinion obtained by Mr and Mrs S found likely negligence but noted an expert medical report was needed to establish causation. After Mrs S passed away in December 2024, Mr S resubmitted the Barrister's opinion, but Aviva maintained its decline, citing a policy term requiring the policyholder to fund supporting evidence. The Ombudsman upheld the complaint, finding that Mr S had established a valid claim and that Aviva should fund the expert medical report as part of its standard claims assessment process. Aviva was ordered to fund the report, reimburse the Barrister's fee with interest, and pay £750 compensation for the additional distress caused.
The Ombudsman's reasoning
The Ombudsman distinguished between what is needed to establish a full legal claim versus what demonstrates a valid claim on the face of it under the insurance policy. Mr S had provided sufficient evidence (Barrister's opinion supporting likely negligence, investigation findings, and care details) to establish a valid claim. The expert medical report recommended by the Barrister is part of the natural evidence-gathering process that a solicitor should undertake and which the insurer should fund, not something the policyholder should be expected to fund before receiving assistance. The panel solicitors had not completed a fair prospects assessment without this report. Aviva's failure to move the claim forward when reassessing all legal opinions caused considerable additional distress to Mr S during an already difficult time.
How this compares
| Group | Decisions | Uphold rate |
|---|---|---|
| Aviva Insurance Limited, all decisions | 5,079 | 27% |
Source
Read the original decision on the Financial Ombudsman Service website