Aviva Protection UK Limited · DRN-6182560

The complaint The estate of Mr S has complained about the decision made by Aviva Protection UK Limited to decline the claim on Mr S’s life insurance policy. The administrator of the estate is Mr S’s widow, Mrs S. She is herself represented by her son, Mr MS. What happened At the end of 2022, the late Mr S applied to an insurer I’ll call A for a life insurance policy. The policy is now administered by Aviva. Mr S very sadly passed away at the end of 2024. So Mrs S submitted a claim to Aviva on behalf of his estate. After reviewing medical information, Aviva declined the claim. They said that Mr S hadn’t accurately disclosed medical information in his application – specifically, that he’d had tests for diabetes and was awaiting follow up. If he’d answered the questions as Aviva say he should have done, they wouldn’t have offered him the policy. So they declined the claim, voided the policy and refunded the premiums to the estate. Mr MS complained to Aviva about their decision. He said A had asked Mr S to take a blood test before underwriting the policy and had asked him to sign an authority allowing them to contact his GP for information. So it was unfair for Aviva to rely on Mr S’s answers to the application to decline the claim. And he complained their questions weren’t clear and about difficulties in communication and getting updates. In their response, Aviva explained that, while they had asked Mr S to take a blood test at the time of the application, the sample had gone astray and, as a gesture of goodwill, they hadn’t asked Mr S to repeat it. And they asked for the authority in case they need to seek medical information, not because they will definitely do so. They didn’t accept their underwriting process was flawed, nor that their questions weren’t clear. Aviva offered £250 compensation for not processing the claim as quickly as they should have done and for the communication difficulties Mr MS had had. But they didn’t change the claim decision. Mr MS didn’t think this resolved the estate’s complaint and brought it to the Financial Ombudsman Service. Our investigator reviewed the information provided by both parties and concluded Aviva didn’t need to do anything different to resolve matters. She was satisfied that, while Mr S had answered “yes” to the question: “Apart from in connection with a condition you’ve already mentioned have you visited your GP in the Last 2 years?....” He hadn’t answered the follow up questions accurately, because he hadn’t said that the blood tests were going to be repeated. She was satisfied that this was a misrepresentation as set out in the Consumer Insurance (Disclosure and Representations) Act 2012 (“CIDRA”) and Aviva had dealt with that misrepresentation as CIDRA required.

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In respect of the blood test for the application, the investigator said the fact that A had requested this didn’t change Mr S’s own obligation to provide accurate information about his health. And, while she noted Aviva had apologised to the family for how they’d dealt with the claim and offered them compensation, she said we couldn’t comment on that because the family aren’t eligible complainants as defined by our rules. Mr MS said the estate didn’t agree with the investigator’s view. So I’ve been asked to make a final decision. 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. Having done that, I’m not upholding the estate’s complaint. I know this isn’t the outcome Mr MS and his family were hoping for. I’ll explain the reasons for my decision, focusing on the points and evidence I consider material to my decision. So if I don’t mention something in particular, it’s not because I haven’t thought about it. Rather, it doesn’t change the outcome of the complaint. My role isn’t to decide whether the claim should be paid. It’s to decide whether Aviva’s decision that it shouldn’t was fair, reasonable and in line with the relevant law. The relevant law in this case is CIDRA. This requires consumers to take reasonable care not to make a misrepresentation when taking out a consumer insurance contract (a policy). The standard of care is that of a reasonable consumer. And if a consumer fails to do this, the insurer has certain remedies - provided the misrepresentation is what CIDRA describes as a “qualifying misrepresentation”. For it to be a qualifying misrepresentation the insurer has to show it would have offered the policy on different terms or not at all if the consumer hadn’t made the misrepresentation. CIDRA sets out a number of considerations for deciding whether the consumer failed to take reasonable care. And the remedy available to the insurer under CIDRA depends on whether the qualifying misrepresentation was deliberate or reckless, or careless. Mr S was diagnosed with diabetes shortly after he applied for the policy. Before that, he was tested periodically and found to be pre-diabetic. Mr MS has said that Mr S didn’t misrepresent his health because A’s application form asked if he had diabetes, not raised blood sugar. I agree with Mr MS that Mr S answered A’s question about diabetes accurately. But that’s not the misrepresentation Aviva say he made. They say the question I’ve set out in the previous section above generated a number of follow ups, in answer to which Mr S said he’d had a routine check. He then answered “no” to the question: “Has any medical treatment or follow up been required following the results of this check up?” Aviva say he should have answered “yes”. I’ve thought carefully about this. And I’ve reviewed the records Aviva relied on to reach that conclusion. The records show that Mr S was pre-diabetic for several years before he bought the policy, that this was discussed with him, that Mr S was reluctant to take medication and preferred to focus on controlling this through diet and lifestyle and that he was advised about how to do

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that. About six weeks before he applied for the policy, the records show Mr S was contacted about recent blood tests, which had showed raised blood sugar. They go onto say: “repeat test in 4 weeks to confirm DM [diabetes mellitus] pt happy with the plan” Mr MS said that, four weeks later was a busy time for Mr S and he didn’t have the tests repeated until about three months later – after he’d bought the policy. But I’m satisfied from the note that Mr S was aware that his routine tests needed to be repeated. And I think the question about follow up is clear. Mr MS has also suggested that it’s unfair to say Mr S made a misrepresentation because A asked him to take a blood test before offering the policy. So they had the chance to check for themselves whether he had any condition which concerned them. It only came to light that the blood test hadn’t been completed when the family claimed on the policy. I have considered this. But I agree with our investigator that it doesn’t change whether Mr S answered the questions accurately, as he was obliged to do. I’m satisfied from his notes he was aware his doctor wanted to conduct follow up tests. He didn’t disclose that. And so I think it’s fair to say Mr S made a misrepresentation. And I’m satisfied that was a qualifying misrepresentation because Aviva have shared underwriting data which confirms that, if they’d known about the follow up tests, A would have postponed offering cover for six months, after which Mr S would have had to re-apply for a policy. In these circumstances, the Association of British Insurers’ Code of Practice allows the application to be treated as declined. Finally, in relation to misrepresentation, I’ve considered the remedy Aviva have applied. The remedy set out in CIDRA varies, depending on whether they categorise a misrepresentation as deliberate or reckless, or as careless. I can’t see that Aviva have told Mr MS how they categorised the misrepresentation. But they’ve declined the claim, voided the policy and refunded the premiums to the estate. That’s the remedy CIDRA says they should apply to a careless misrepresentation where they wouldn’t have offered the policy at all. I think that’s fair. I’ve noted that Mr MS wasn’t happy with the service he received during the consideration of the claim. Aviva have acknowledged that fell short of what it should have been and offered him £250 compensation. It’s not clear whether Mr MS has accepted that, or whether it’s been paid. But, as our investigator explained, I can’t make any direction in relation to compensation because I can only direct an award to an eligible complainant. In this case, that’s the estate – not the person who’s been distressed or inconvenienced. If Mr MS hasn’t received this sum and now wants to accept it, he will need to contact Aviva directly about this. Mr MS has outlined the financial stresses his family have been caused by Aviva not settling the claim. I’m sorry my decision won’t make those any easier. But, for the reasons I’ve explained, I don’t think Aviva need to do any more to resolve the estate’s complaint. My final decision For the reasons I’ve explained, I’m not upholding the complaint Mr MS has made about Aviva Protection UK Limited on behalf of the late Mr S’s estate. Under the rules of the Financial Ombudsman Service, I’m required to ask the estate of Mr S

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to accept or reject my decision before 1 April 2026. Helen Stacey Ombudsman

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