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

Decision detail

Summary

Mrs B claimed income protection benefit for tenosynovitis and began receiving payments in 2023. She started a phased return to work in January 2024 and Aviva ceased her benefit in June 2025 after reviewing medical records showing no GP attendance for her condition in over 12 months. Mrs B argued Aviva should have conducted an independent medical examination before stopping payments and that the CMO's assessment was based on unfair assumptions. The ombudsman found Aviva's decision was reasonable and fair, as the absence of medical records for over a year, combined with Mrs B's successful return to work and declining of additional treatment, supported the conclusion that her symptoms had resolved. The ombudsman rejected the requirement for an independent medical examination, noting Aviva had fairly invited Mrs B to submit contrary medical evidence, which she did not provide.

The Ombudsman's reasoning

The ombudsman found that Aviva reasonably determined Mrs B was no longer incapacitated based on the absence of medical records for over 12 months, her successful phased return to work, and her declining additional treatment. While the CMO's opinion relied partly on assumption, it was reasonable in circumstances where Aviva invited Mrs B to submit contrary medical evidence, which she did not do. An independent medical examination was not required as usual practice is to first review up-to-date medical records, and Aviva had done so fairly.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website