Not upheld: claim decline - non-disclosure of pre-existing medical conditions complaint against Aviva Insurance Limited

Decision detail

Summary

The estate of Mr E complained that Aviva Insurance Limited unfairly declined a travel medical claim for repatriation costs following a stroke suffered during a holiday in October 2024. Aviva declined the claim on the basis that the late Mr E failed to declare his pre-existing cerebral amyloid angiopathy (CAA) condition, diagnosed in 2018. The estate argued that Aviva was aware of the condition and that a March 2024 neurologist appointment was solely to discuss a recent cardiac arrest, not the CAA. The ombudsman found that the March 2024 appointment was also to assess the impact of intended heart treatment on the CAA condition, with a follow-up scheduled, placing it within the 12-month declaration period. The ombudsman upheld Aviva's decline as the late Mr E failed to declare the pre-existing condition that directly caused the stroke, and the policy clearly excludes undeclared pre-existing conditions.

The Ombudsman's reasoning

The ombudsman found that the late Mr E's CAA was a pre-existing medical condition that should have been declared under the policy terms. Although the March 2024 neurologist appointment was primarily to discuss the recent cardiac arrest, the evidence showed it was also to assess the impact of intended heart treatment on the CAA condition, with a follow-up appointment scheduled for February 2025. This appointment fell within the 12-month declaration period preceding the October 2024 holiday, meaning the late Mr E was aware of and under active management for the CAA condition. The stroke in October 2024 was directly related to this undeclared pre-existing condition. Aviva's enquiries were reasonable and its retrospective screening showed it would have excluded claims related to CAA or brain haemorrhages had the condition been declared. The policy clearly excludes cover for any medical condition unless declared and agreed in writing.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website