Not upheld: claims handling and failure to warn of specialist suspension complaint against Aviva Insurance Limited
Financial Ombudsman decision DRN-6351998 of 2026-05-21T00:00:00+00:00. claims handling and failure to warn of specialist suspension complaint against Aviva Insurance Limited. Outcome: Not upheld.
Decision detail
| Reference | DRN-6351998 |
|---|---|
| Decision date | 2026-05-21T00:00:00+00:00 |
| Firm | Aviva Insurance Limited |
| Product | private medical insurance |
| Claim type | claims handling and failure to warn of specialist suspension |
| Outcome | Not upheld |
| Remedy | £200 compensation already paid by Aviva for failing to appropriately address Mr H's concerns. No further action required. Ombudsman noted that if Mr H has not cashed the cheque, he should contact Aviva to arrange alternative payment method. |
Summary
Mr H complained to the FOS about Aviva's handling of his private medical insurance claim following treatment with specialist Miss X. Mr H alleged that Miss X had been suspended but remained on Aviva's approved list, and that Aviva failed to warn him to stop treatment or question its clinical appropriateness. In June 2025, the hospital group withdrew Miss X's privileges on commercial grounds, and Mr H subsequently received a diagnosis of severe joint disease from another specialist. Aviva offered £200 compensation for delayed complaint response but did not uphold Mr H's substantive complaints. The ombudsman found Aviva's processes for monitoring specialist status were reasonable, that there was no evidence of widely-known concerns at the time of referral, and that Aviva was not obligated to advise cessation of treatment based on commercially-motivated privilege withdrawal without clinical safety concerns. The complaint was not upheld.
The Ombudsman's reasoning
The ombudsman distinguished between Aviva's responsibility for specialist selection (a commercial decision) and its duty to treat Mr H fairly in specific circumstances. The ombudsman found that Aviva's reliance on hospitals and GMC registration checks to identify changes in specialist status was reasonable, and there was insufficient evidence that concerns about Miss X were widely known at the time of referral. Regarding the June 2025 notification, the ombudsman determined that because the privilege withdrawal was stated as commercial rather than clinical in nature, Aviva was not obligated to advise Mr H to cease treatment, as doing so without clinical safety concerns could have interrupted necessary treatment. The ombudsman acknowledged Aviva's delay in responding to Mr H's concerns caused unnecessary distress but considered the £200 compensation reasonable given the circumstances.
How this compares
| Group | Decisions | Uphold rate |
|---|---|---|
| Aviva Insurance Limited, all decisions | 5,098 | 27% |
Source
Read the original decision on the Financial Ombudsman Service website