Not upheld: Home insurance claim disputes complaint against Aviva Life & Pensions UK Limited

Decision detail

Summary

Mr S complained that Aviva unreasonably rejected his critical illness insurance claim for ocular melanoma. Aviva relied on an associated condition exclusion in the group policy, arguing that Mr S's pre-existing choroidal naevus was related to the melanoma and the cancer developed within two years of joining the scheme. The ombudsman upheld Aviva's decision, finding that specialist medical opinion confirmed the choroidal naevus underwent malignant transformation into cancer and the two conditions were related. Since Mr S had the naevus before joining and the melanoma developed within two years, the exclusion applied. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman applied FCA industry rules requiring insurers not to unreasonably reject claims. The policy contained an associated condition exclusion that applies when a member had an associated condition prior to cover commencing and the critical illness occurred within two years of joining, unless a critical illness or operation occurred in the first two years. Specialist medical opinion confirmed the choroidal naevus was related to the occurrence of cancer. Since Mr S had the choroidal naevus before joining the scheme and the melanoma developed within two years of joining, the claim fell within the exclusion. The ombudsman rejected Mr S's argument that choroidal naevus is not a medical condition, noting that Aviva's medical adviser, the ophthalmologist, and online references all described it as a condition.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website