Not upheld: claim rejection - undeclared pre-existing medical conditions complaint against Aviva Insurance Limited

Decision detail

Summary

Mr R and Mrs R complained that Aviva Insurance Limited unreasonably declined their travel insurance claim for trip cancellation costs following the late Mr R's hospitalisation and death. The trip was booked in May 2024 for June 2024 travel but was cancelled after the late Mr R was admitted to hospital with pre-existing conditions (ischaemic cardiomyopathy and chronic kidney disease). Aviva declined the claim on the basis that these pre-existing conditions had not been declared to it, contrary to policy requirements. Mrs R claimed she had previously disclosed the conditions to the previous insurer U and that they were accepted, and that she had called Aviva before booking to confirm requirements. The ombudsman found that Mrs R's recollection of declaring the conditions to Aviva was not supported by Aviva's records, communication logs showing first contact on 29 May 2024 when the late Mr R was already hospitalised, or confirmation from Aviva's medical screening team. The ombudsman also found that even if the conditions had been declared, Aviva's underwriting assessment showed it would not have covered them due to the combination exceeding its risk threshold. Therefore, the ombudsman concluded Aviva reasonably declined the claim and did not uphold the complaint.

The Ombudsman's reasoning

The ombudsman applied FCA industry rules requiring insurers not to unreasonably reject claims. The policy clearly required declaration of pre-existing medical conditions within 12 months before booking. The late Mr R's conditions (ischaemic cardiomyopathy and chronic kidney disease) met the declaration criteria as he was on repeat prescription medication and had been referred to a specialist. The ombudsman found these conditions directly caused or contributed to his hospitalisation and death, necessitating trip cancellation. Although Aviva could have strictly applied policy terms to decline the claim, the ombudsman considered what Aviva would have done if conditions had been declared. Aviva's underwriting evidence demonstrated it would not have covered the late Mr R's conditions regardless. The ombudsman found Mrs R's recollection of declaring conditions to Aviva was not supported by Aviva's records, communication logs, or medical screening team confirmation. The first recorded contact was 29 May 2024 when the late Mr R was already hospitalised. Therefore, the ombudsman concluded it was reasonable for Aviva to decline the claim as the cancellation resulted from undeclared pre-existing conditions that would not have been covered anyway.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website