Not upheld: claim declined - undiagnosed medical condition exclusion complaint against Aviva Insurance Limited

Decision detail

Summary

Mr S claimed on his travel insurance policy for cancellation costs after receiving a hospital appointment that coincided with his planned trip. Aviva declined the claim on the basis that Mr S had an undiagnosed medical condition (abdominal problems with elevated inflammatory markers pending specialist investigation) at the time of booking, which was excluded from cover under the policy terms. Mr S argued that he had disclosed medical information on a separate travel policy with another bank, also underwritten by Aviva, and that this should have been considered. The ombudsman found that the two policies were completely separate, Aviva had made clear it required up-to-date information for this claim, and the medical evidence confirmed Mr S had not received a full diagnosis at the time of booking. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman applied the contractual test of whether the claim falls within the agreed areas of cover. The policy explicitly excludes claims arising from undiagnosed conditions where a diagnosis has been sought but not yet received. Although Mr S had received some test results (elevated inflammatory markers), the medical evidence confirmed he had not received a full diagnosis and required further specialist investigation. Mr S himself confirmed during the phone interview that he had not received a diagnosis at the time of booking. The ombudsman rejected Mr S's argument that information from his separate Bank B policy should have been considered, as the policies are completely separate and Aviva made clear it required up-to-date information for this claim. Even if such information had been considered, it would not have changed the outcome as Aviva declined the claim specifically because the condition was undiagnosed, not because of failure to declare pre-existing conditions.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website