Aviva Insurance Limited · DRN-6155608

The complaint Mr S complains because Aviva Insurance Limited restricted cover for a medical condition under his private medical insurance policy. What happened Mr S is insured under a private medical insurance policy, provided by Aviva. In 2025, Aviva gave Mr S six months’ notice that it would no longer cover a medical condition, as it said it considered it to be chronic. However, Aviva said if surgery was recommended it would assess a claim for this. Unhappy, Mr S complained to Aviva before bringing the matter to the attention of our Service. One of our Investigators looked into what had happened and said he didn’t think Aviva had acted unfairly or unreasonably in the circumstances. Mr S 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. The role of the Financial Ombudsman Service is to make an independent and impartial decision based on the evidence provided to us by the parties involved. We don’t generally arrange our own independent medical reviews, nor would I generally expect an insurer to arrange for one in a situation such as this. Like most, if not all, private medical insurance policies available on the market, the policy Mr S holds excludes cover for chronic conditions. Subject to certain exceptions, Mr S’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 requires your rehabilitation or for you to be specially trained to cope with it • it continues indefinitely • it has no known cure • it comes back or is likely to come back.’

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I understand Mr S and his doctor don’t consider his medical condition to be chronic, but Aviva is entitled to assess the claim against its policy definitions. The policy terms and conditions set out Aviva’s obligations to Mr S and it’s the policy definition of ‘chronic’ which is relevant here, not what Mr S or his doctor consider a chronic condition to be. Aviva has provided cover for this condition since 2016 and paid claims for consultations and treatment in that year, as well as in 2019, 2023, 2024 and 2025. I understand what Mr S has said about the nature of his medical treatment, that he was previously discharged from consultations and that he isn’t on any medication. I’ve also taken into account what Mr S has told us about his activity levels, as well as his doctor’s comments. But, overall, I don’t think Aviva has acted unfairly or unreasonably in the circumstances by classifying his condition as chronic under the definition set out in Mr S’s policy. And Aviva gave Mr S what I’d consider to be reasonable notice that it would no longer cover the condition. I’m sorry to disappoint Mr S and I understand he feels strongly about the matter, 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 S’s complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr S to accept or reject my decision before 17 April 2026. Leah Nagle Ombudsman

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