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

Decision detail

Summary

Mr and Mrs W, as trustees of the W trust, complained that Aviva unfairly declined a critical illness claim following Mr W's prostate cancer diagnosis and cancelled his life and critical illness policy, citing misrepresentation in the application. Mr W had answered 'no' to questions about heart conditions and raised blood pressure, but medical records revealed he had undergone atrial fibrillation ablation 15-20 years prior and had raised blood pressure in 2017-2019. The ombudsman applied CIDRA 2012 and found the questions were clear and unambiguous, requiring disclosure of historic resolved conditions. Mr W's failure to disclose constituted a qualifying misrepresentation, as Aviva evidenced they would not have offered the policy with accurate information. The ombudsman rejected arguments about language barriers and reliance on the selling agent, noting these were matters for the separate selling business. The complaint was not upheld, as Aviva's decision to decline the claim and cancel the policy with premium refund was fair and reasonable under CIDRA.

The Ombudsman's reasoning

The ombudsman applied the Consumer Insurance (Disclosure and Representations) Act 2012 (CIDRA), which requires consumers to take reasonable care not to make misrepresentations. The questions asked were clear and used the phrase 'have you ever', indicating that historic resolved conditions should be disclosed. Mr W's failure to disclose his atrial fibrillation ablation and raised blood pressure constituted a qualifying misrepresentation because Aviva provided evidence they would not have offered the policy had accurate information been given. The misrepresentation was categorised as deliberate or reckless because Mr W knew about the procedure but did not disclose it, believing it was not relevant—an unreasonable conclusion given the clear wording of the questions. Even if categorised as careless, CIDRA permits cancellation and premium refund when the insurer would never have offered the policy, which Aviva did. Aviva provided clear information in the policy documents about the importance of accurate information and the consequences of misrepresentation.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website