Not upheld: claim rejection based on policy exclusion for pre-existing associated condition complaint against Aviva Life & Pensions UK Limited

Decision detail

Summary

Mr P complained that Aviva Life & Pensions UK Limited unfairly rejected his critical illness claim following a heart attack in February 2025. Mr P was insured under his employer's group critical illness policy from June 2024. Aviva declined the claim because Mr P had been diagnosed with hypertension in April 2024, before his cover commenced, and the policy explicitly excluded cover for heart attack claims where an insured person had an associated condition prior to the start of cover. The ombudsman found Aviva acted fairly and reasonably in applying the contractual exclusion, as the medical evidence clearly established the pre-existing hypertension diagnosis. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that Aviva clearly set out the exclusion for associated conditions in the policy terms and that hypertension was explicitly listed as an associated condition for heart attack claims. The medical evidence clearly showed Mr P had been diagnosed with hypertension in April 2024, before his cover commenced in June 2024. Therefore, Aviva was reasonably entitled to rely on the contractual exclusion to decline the claim. The fact that Mr P may not have been aware he had hypertension does not change the outcome, as Aviva did not individually underwrite Mr P's cover and the exclusion applies based on objective medical evidence.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website