Not upheld: unfair claim decline complaint against Aviva Life & Pensions UK Limited

Decision detail

Summary

Ms A claimed on a life and critical illness insurance policy underwritten by Aviva for Rheumatoid Arthritis. Aviva declined the claim, stating Ms A did not meet the policy definition of critical illness, which required inability to perform three Activities of Daily Work without help, with the disability being permanent and irreversible. Ms A provided her GP's confirmation of diagnosis and her own testimony about her limitations, but no objective medical evidence. Aviva offered an independent assessment to establish her functional limitations, which Ms A refused. The ombudsman upheld Aviva's decision, finding that the request for an independent assessment was reasonable and within the policy terms, and that without such objective evidence, Aviva did not act unfairly in declining the claim.

The Ombudsman's reasoning

The ombudsman applied the relevant policy terms which required objective medical evidence that the claimant met the definition of critical illness, specifically inability to perform three Activities of Daily Work without help, with the disability being permanent and irreversible. While Ms A provided a diagnosis and her own testimony about her limitations, there was no medical evidence documenting her functional restrictions. The ombudsman found Aviva's request for an independent assessment was reasonable and within the policy terms, which explicitly permitted Aviva to request a visit to a health professional of their choosing. Without such objective evidence, the ombudsman could not conclude that Aviva acted unfairly in declining the claim.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website