Aviva Insurance Limited · DRN-6257297

The complaint Mr M complains about the decision by Aviva Insurance Limited (‘Aviva’) to apply a chronic condition exclusion under his employer’s group private medical insurance policy. What happened Mr M has been a member of his employer’s group private medical insurance scheme, which is provided by Aviva, since 2013. In November 2024, Mr M was diagnosed with a type of autoimmune disorder. He pursued a claim, which was accepted by Aviva. However, Aviva told Mr M in August 2025 that it would no longer be able to meet the cost of the claim because it considered Mr M’s condition to be chronic. And in relation to his diagnosis, it usually only offered cover for six months. Mr M complained. In September 2025, Aviva confirmed it was not prepared to change its decision. It said it considered Mr M’s condition to be chronic, with ongoing monitoring. It recognised that Mr M had encountered his first episode of a severe metabolic surge due to his autoimmune condition and so the intention of the medication was curative. However, Mr M required regular blood tests and consultations to monitor his response treatment, and it considered that to be ongoing management under the policy definition of chronic condition. Aviva did, however, agree to cover one further follow up appointment in November 2025. Mr M brought his complaint to this service, where it was reviewed by one of our investigators. She did not believe that Aviva had acted unfairly in defining Mr M’s condition as chronic, in its review of the medical evidence or by applying the policy terms relating to chronic conditions to Mr M’s claim. She noted how Mr M’s policy was designed to provide benefit for acute symptoms on a short-term basis and is not designed for any routine management or monitoring of chronic conditions. Mr M disagreed. He provided a number of detailed documents, including a clinical evidence summary, a written set of submissions for an ombudsman and a further additional written submission. I have read and reviewed these in their entirety, though I shan’t repeat their content here. In summary, Mr M said: • The letters from Mr J, consultant physician specialising in endocrinology, from August and November 2025 both describe his treatment as having a planned end point – so this cannot indicate he has a chronic illness. • Though the investigator has suggested otherwise, he doesn’t concede the disease is chronic. • The autoimmune marker that drives his condition has declined continuously over the last 13 months, reaching the upper range of normal as at November 2025. • His relapse in April 2025 was due to a medicine change, not spontaneous disease recurrence. • Aviva made a blanket assertion that his type of autoimmune disease doesn’t have • ‘unexpected’ acute flare ups without distinguishing between spontaneous disease flare-ups and an iatrogenic relapse caused by clinician-directed dose reduction.

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• Applying a six-month time limit to his disease is inappropriate, as severe presentations of his type of disorder usually require longer treatment courses to resolve. • The wording Aviva relies on in respect of the six-month limit contains the word ‘usually’ and therefore must indicate discretion rather than it being a contractual provision. • The policy wording does offer cover for curative services, and his physician plans to cure the disorder. • Having to pay out of pocket now has cost him some £2,000 to £3,000. • He does not agree with the way the policy wording for a chronic condition has been interpreted. • He also feels our investigator misunderstood the distinction between treatment response and treatment duration. • Other conditions under the policy have cover periods up to two years without being classed as chronic – such as ADHD and hormone treatment for gender identity. Mr M feels that this cannot provide a fair outcome for members of Aviva’s schemes. • Since February 2026, Mr M has suffered consequential harm to his mental health. He submits that Aviva's withdrawal of cover mid-treatment led to unsupervised self- management of his disease, which contributed to a medical crisis requiring psychiatric intervention. • Mr M wants an ombudsman to consider compensation for distress an inconvenience, reflecting his medical crisis and the burden of pursuing this complaint whilst unwell. Aviva didn’t have any other comments to make. The complaint has now been passed to me. 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. Before I go any further, I’d like to recognise that Mr M has been going through some challenging circumstances recently, and I send him my best wishes. I recognise the depth of feeling Mr M has about this matter and I thank him for the time and detail taken over the extensive representations he has made to this service. That being said, I won’t be addressing every individual submission that he has have made in turn. I do not intend that as a discourtesy to the parties. I’ve fully reviewed all the information before me. in reaching my findings, I’ve focused on what I consider to be the central issues. I don’t need to comment on every argument to be able to reach what I think is the right outcome in the circumstances. Our rules allow me to take this approach; it reflects the informal nature of our service, as a free alternative to the courts. Having reviewed this complaint carefully, though I realise my decision won’t be what Mr M has hoped for, I agree with the outcome reached by our investigator; that means I do not believe Aviva needs to do anything further to resolve this complaint. My findings are: • It's important that I make the parameters of this decision clear. I will only be considering the evidence which was available to Aviva up to the point it issued its final response to Mr M’s complaint in September 2025, endorsing its decision to discontinue the claim payment.

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• The relevant regulatory rules and industry guidance say that BUPA has a responsibility to handle claims promptly and fairly and it shouldn’t reject a claim unreasonably. • So, I’ve considered Mr M’s employer’s group scheme terms and conditions against the circumstances of his claim. Mr M’s employer’s group scheme does not provide benefit for outpatient treatment involving monitoring or management of chronic conditions or any flare-ups of a chronic condition. • Mr M’s group policy wording says: “The purpose of this policy is to cover you during a period of cover for the treatment of acute conditions on a short-term basis. Except as otherwise stated below, all treatment and diagnostic tests must be by, and under the care of, specialists following referral from your GP. An acute condition is defined as: A disease, illness or injury that’s likely to respond quickly to treatment which aims to return you to the state of health you were in immediately before suffering the disease, illness or injury or which leads to your full recovery. A chronic condition is defined as: A disease, illness or injury that has one or more of the following characteristics: o it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and/or tests o it needs ongoing or long-term control or relief of symptoms [[my emphasis] o it requires your rehabilitation or for you to be specially trained to cope with it o it continues indefinitely o it has no known cure o it comes back or is likely to come back.” • The policy wording also sets out an exclusion for chronic conditions which says: “Benefits will not be available for: 1. Treatment b. of any condition that is a chronic condition. In particular: o regular planned check-ups for a chronic condition where you are likely to need treatment o expected deterioration of a chronic condition which needs regular consultations, diagnostic tests or treatment from a specialist [my emphasis]. BUT: o We do cover unexpected acute flare-ups of a chronic condition until your condition is re-stabilised o We do not apply this chronic condition exclusion to treatment for cancer.”

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• My understanding on the information I have seen is that Mr M’s condition can be managed effectively through medication to achieve remission, rather than a curative intent. In any event, it is clear from the policy wording as to what Aviva deems to be a chronic condition, and it is those terms it had to apply to the medical evidence it received regarding Mr M’s ongoing treatment. I have considered if it was fair and reasonable for Aviva to conclude that Mr M has a chronic condition under the terms – and I believe it was. I say this noting how Mr M has accepted he requires both treatment and monitoring over more than a short term. • I recognise that in his submission to our service in December 2025 Mr M said he believes he requires treatment for an acute relapse. However, Mr M also concedes that treatment has to continue for 12-18 months to avoid relapse risk or the need for further intervention (acute or otherwise). And he recognises that the medicine he takes requires close monitoring because of the risk of adverse effects. • By the time Mr M met with his physician in August 2025, he had been in receipt of medication for nine months, with the flare up of his condition (whether that was acute, or not) some six months previously. And the physician explained Mr M had discovered a family history of his condition. He also said “As noted previously, it would be worth continuing [a type of] drug therapy for at least a year, with discontinuation timing also guided by [autoimmune markers]”. I am satisfied that Aviva has reasonably interpreted this as long-term and ongoing. • I realise that the policy terms do not include an express exclusion for Mr M’s condition. However, there isn’t a requirement for Aviva to cover every conceivable condition that a member of the scheme may suffer from. On general grounds, most private healthcare providers exclude chronic conditions because including cover on that basis would make the cost of private healthcare prohibitive. • Mr M is also unhappy with Aviva’s internal underwriting guidance used for his condition. I cannot repeat the content of that guidance in full here, since it is confidential and Aviva will not permit us to publish it. Nonetheless, I am satisfied that the guidance is clear in stating that it will provide benefit for newly diagnoses where a certain medicine is recommended as a first line treatment – and that applied to Mr M – but it otherwise classes all instances of diagnosis of Mr M’’s specific autoimmune disease as chronic after six months. • We do not act in the capacity of a regulator. That remit falls to the Financial Conduct Authority, where it may look at wider issues governing how businesses conduct their operations or exercise what may be commercial judgement on the provision of a particular service. It follows that I cannot make findings on the guidance in place for Mr M’s condition set by Aviva. What I am able to do is determine if it treated him equitably in the face of that guidance – and I believe it did. • Given Aviva did not make it immediately clear about the six-month limit for payment of claims for new diagnoses of Mr M’s condition, it agreed to cover Mr M up to November 2025. I find that fair in the circumstances as it is twice the period usually agreed to, because of that initial omission. • I am satisfied that it was reasonable for Aviva to apply the chronic condition exclusion. It gave Mr M sufficient notice of its intention to withdraw cover, as I’d expect, and it went beyond the proposed withdrawal date by paying an additional claim for a consultation to Mr M in November 2025.

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• I am sorry to disappoint Mr M, but on the information I’ve seen to date there does not appear to be any basis on which I could reasonably require Aviva to pay his claim. I am of the view that Aviva has objectively applied the policy wording to his circumstances, and I don’t find it fair or reasonable to ask it to meet a claim outside of the terms and conditions for the employer’s group scheme. My final decision Despite my sympathy for Mr M’s position, I cannot uphold his complaint. I find WPA to have acted fairly and reasonably when withdrawing cover for his autoimmune disorder and so I cannot ask it to do anything further. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr M to accept or reject my decision before 28 April 2026. Jo Storey Ombudsman

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