Not upheld: Travel / life insurance claim disputes complaint against Aviva Life & Pensions UK Limited

Decision detail

Summary

Mr and Mrs M complained that Aviva unfairly declined Mr M's TPD claim and retrospectively changed the applicable TPD definition from 'own occupation' to 'activities of daily work'. The ombudsman found that Mr M had failed to take reasonable care when answering the application question about the percentage of manual work in his role, stating 10% when his role actually involved approximately 80% manual work. This was a careless qualifying misrepresentation under CIDRA, as evidenced by Mr M's own later statements and prior application information. Aviva was entitled to assess the claim using the definition that would have been offered had the correct information been provided. Based on medical evidence, Mr M did not meet the 'activities of daily work' definition, so the claim was fairly declined. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that the manual work question was reasonably clear and that Mr M failed to take reasonable care in answering it, as evidenced by his own later statements that his role was approximately 80% manual work. This constituted a careless qualifying misrepresentation under CIDRA. Aviva's underwriting evidence demonstrated the misrepresentation was material—the policy would have been offered with a different TPD definition had the correct information been provided. Under CIDRA, Aviva was entitled to assess the claim using the definition that would have applied had the misrepresentation not occurred. Based on medical evidence, Mr M did not meet the 'activities of daily work' definition, so the claim was fairly declined.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website