Not upheld: claim declined - coverage ended upon employment termination complaint against Aviva Insurance Limited

Decision detail

Summary

Miss N complained that Aviva unfairly declined her claim for medical treatment received on 13 August 2025, after she had resigned from her employment on 8 August 2025. Although Aviva had confirmed pre-authorisation before she left and later told her cover remained in place, Aviva subsequently declined the claim after being informed by her employer that she no longer worked there. The ombudsman found the policy terms clearly state membership ceases upon employment termination even if treatment was pre-authorised, and that Aviva's incorrect information on 27 August was based on information available at that time. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that the policy terms clearly state membership may cease immediately or on an agreed date when an employee leaves their company, even if treatment was pre-authorised. The contract was between Aviva and the employer, not Miss N directly, making the employer responsible for confirming the end date. While Aviva provided incorrect information on 27 August, this was based on information available at that time before being notified of the employment termination. The ombudsman concluded Aviva was not obligated to contact Miss N about the pre-authorisation ending and fairly declined the claim.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website