Not upheld: claim denial - incorrect medical classification assessment complaint against Aviva Life & Pensions UK Limited

Decision detail

Summary

Mr L claimed on his life and critical illness policy after being diagnosed with prostate cancer in 2024. Aviva declined the claim because Mr L's Gleason score was 6 (policy requires greater than 6) and his TNM classification was assessed as T1cN0M0 rather than the required T2N0M0 or higher. Mr L's consultants had classified his cancer as T2, but Aviva's medical officers concluded it should be T1 based on the tumour not being detectable on DRE and having a borderline PI-RADS imaging score of 3. The ombudsman found Aviva's decision reasonable, as the policy requires TNM classification and Aviva was entitled to verify the consultants' classification through their own medical experts. Aviva had previously paid £650 compensation for service delays and poor communication.

The Ombudsman's reasoning

The ombudsman concluded that Aviva's decision to classify Mr L's tumour as T1cN0M0 rather than T2N0M0 was reasonable based on the available medical evidence. The key finding was that Mr L's tumour was not detectable on DRE (a requirement for T2 classification) and had a PI-RADS score of 3 (borderline imaging, meaning cancer could not be diagnosed from imaging alone). While Mr L's consultants classified the tumour as T2, they used a different classification system, and the policy explicitly requires TNM classification. The ombudsman found it reasonable for Aviva to seek verification of the consultants' classification through their own medical experts, particularly given one conflicting report. The ombudsman acknowledged not being a medical expert and could only assess whether Aviva's decision was reasonable, not which medical classification was correct.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website