Not upheld: claim rejection based on existing medical conditions exclusion complaint against Aviva Insurance Limited

Decision detail

Summary

Mr and Mrs R held a travel insurance policy with Aviva that included medical conditions cover expiring in December 2024. After the cover expired, Mr R informed Aviva in January 2025 that his aneurysm had been repaired but declined to purchase additional cover. When Mr R suffered a stroke in February 2025 after booking a holiday, Mr and Mrs R cancelled and claimed on the policy. Aviva declined the claim, citing the existing medical conditions exclusion because Mr R had not disclosed his recent aneurysm surgery and PAF medication within the required six-month disclosure period. The ombudsman found Aviva acted fairly and reasonably in declining the claim, as the policy terms clearly required disclosure of such conditions and Aviva had communicated this requirement to the customers.

The Ombudsman's reasoning

The ombudsman found that Aviva's reliance on the existing medical conditions exclusion was justified. The policy clearly required disclosure of medical conditions within six months prior to booking a trip, and Aviva had made this requirement known to Mr and Mrs R. Mr R had not obtained confirmation of cover for his recent aneurysm surgery or his PAF medication before the holiday was booked in February 2025. It was not Mr R's role to determine risk; that was Aviva's responsibility as the insurer. The medical evidence supported that both the aneurysm surgery and PAF medication fell within the relevant six-month disclosure period, and Aviva reasonably concluded that PAF was related to the subsequent stroke.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website