Aviva Insurance Limited · DRN-6132217

The complaint Mr C complains because Aviva Insurance Limited said it would no longer cover his medical condition under a private medical insurance policy. What happened Mr C is insured under a private medical insurance policy, provided by Aviva. Aviva opened a claim for Mr C in 2022, when he saw a Consultant Cardiologist. Following further reviews, tests and monitoring in 2023 and 2024, Mr C had a medical procedure in 2025. Aviva paid for this but, later in 2025, it gave Mr C two months’ notice that it would no longer cover the medical condition as it considered it to be chronic. Unhappy, Mr C complained to Aviva before bringing the matter to the attention of our Service. One of our Investigators looked into what had happened and said she didn’t think Aviva had acted unfairly or unreasonably in the circumstances. Mr C didn’t agree with our Investigator’s opinion, so the complaint has now been referred to me to make a decision as the final stage in our process. What I’ve decided – and why I’ve considered all the available evidence and arguments to decide what’s fair and reasonable in the circumstances of this complaint. Industry rules set out by the regulator say insurers must handle claims fairly and shouldn’t unreasonably reject a claim. I’ve taken these rules into account when making my final decision. Like most, if not all, private medical insurance policies available on the market, the policy Mr C is insured under excludes cover for chronic conditions. Subject to certain exceptions, Mr C’s policy doesn’t cover the following: ‘A disease, illness or injury that has one or more of the following characteristics: • it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and/or tests • it needs ongoing or long-term control or relief of symptoms … • it continues indefinitely • it has no known cure

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• it comes back or is likely to come back.’ I understand Mr C doesn’t consider his medical condition to be chronic, but Aviva is entitled to assess the claim against its policy definitions. While I understand what Mr C has said about the condition not being initially diagnosed in 2022 and his comments about the nature of the upcoming 2026 appointment, I don’t think Aviva has acted unfairly or unreasonably in the circumstances by classifying his condition as chronic. And Aviva gave Mr C what I’d consider to be reasonable notice that it would no longer cover the condition. I’m sorry to disappoint Mr C and I understand this matter has caused him distress, but I don’t think Aviva has acted unfairly or unreasonably in the circumstances, so I won’t be directing it to do anything more. My final decision My final decision is that I don’t uphold Mr C’s complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr C to accept or reject my decision before 16 April 2026. Leah Nagle Ombudsman

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