Not upheld: claim decline - causation dispute complaint against Avon Insurance Plc

Decision detail

Summary

Mr C claimed on a personal accident insurance policy after undergoing knee replacement surgery in January 2026 following a March 2025 accident. Avon declined the claim, stating the medical evidence indicated the replacement was necessary due to pre-existing knee arthritis rather than being solely caused by the accident. Mr C provided a revised GP letter stating the surgery was directly due to the accident, but the ombudsman found this letter was inconsistent with earlier medical records and the GP's initial response. The ombudsman upheld Avon's decision as the policy required the accident to be the direct cause of the need for surgery, which the available medical evidence did not support.

The Ombudsman's reasoning

The ombudsman found that the policy required Mr C to demonstrate the accident directly caused the total, permanent, irreversible loss of movement of his knee, not merely that he had an accident and subsequently had surgery. The available medical evidence, including GP records, consultant letters, and urgent treatment centre notes, consistently indicated that Mr C had pre-existing knee arthritis and was awaiting replacement before the accident occurred. While the accident exacerbated his symptoms, the evidence did not support that it was the sole direct cause of the need for surgery. The GP's revised letter provided after the claim decline was inconsistent with the GP's earlier response and the wider body of medical evidence, making it unreasonable to rely upon it to overturn Avon's decision.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website