Not upheld: claim rejection and handling complaint against Aviva Insurance Limited

Decision detail

Summary

Mr P complained to Aviva about how it handled his claim for knee pain treatment under his employer's private medical insurance policy. He made the claim on 28 July 2025 and was directed through Aviva's third-party healthcare provider pathway, receiving a telephone consultation and physiotherapy assessment in early August 2025. However, the employer's policy had ended on 31 July 2025, so Aviva did not cover the treatment costs, and Mr P was charged for the services. The ombudsman found that although the timing appeared unfair to Mr P, Aviva's claims team was unaware the policy was ending when the claim was made, and the policy terms clearly limited cover to treatment during the period of cover. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that Aviva correctly directed Mr P through the pathway as specified in the policy terms. The policy clearly states cover is limited to treatment during the period of cover, which ended 31 July 2025. Although Mr P made his claim before the policy ended, the actual treatment occurred in early August after the policy had terminated. The ombudsman considered the timing unfair from Mr P's perspective but found Aviva acted reasonably given that the claims team was unaware of the imminent policy cancellation when the claim was made. The ombudsman determined it was the employer's responsibility, not Aviva's, to notify Mr P of the policy termination and its implications.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website