Aviva Life & Pensions UK Limited · DRN-6222284

The complaint Miss M has complained that Aviva Life & Pensions UK Limited declined a critical illness claim. What happened Miss M took out a critical illness policy though an independent intermediary. The cover commenced on 12 November 2024. When Miss M was diagnosed with a glioma brain tumour later that month, she raised a claim on her critical illness policy. Aviva declined the claim. It said that had Miss M answered the questions correctly when taking out the policy she wouldn’t have been offered cover. It cancelled the policy and refunded the premiums paid. Other policies taken at the same time were also cancelled but this complaint arises from the critical illness claim only. Unhappy Miss M referred her complaint to our Service. The investigator didn’t recommend that it be upheld. They didn’t conclude that Aviva had done anything wrong. Miss M appealed. She said that she had answered the relevant question correctly and believed that other GPs agreed with her. As no agreement has been reached the matter has been passed to me to determine. 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. I’m aware I’ve summarised the background to this complaint and some sensitive medical details. No discourtesy is intended by this. Instead, I’ve focused on what I find are the key issues here. Our rules allow me to take this approach. It simply reflects the informal nature of our service as a free alternative to the courts. If there’s something I haven’t mentioned, it isn’t because I’ve ignored it. I’ve fully reviewed the complete file and having done so I agree with the conclusion reached by our investigator. I’ll explain why. The relevant law in this case is The Consumer Insurance (Disclosure and Representations) Act 2012 (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.

-- 1 of 2 --

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. Aviva concluded that Miss M failed to take reasonable care not to make a misrepresentation when answering the following question: Within the last ten years have you: Had any of these symptoms? Blurred or double vision, Numbness, persistent pins and needles or loss of muscle power, Balance problems or dizziness, Tremor, Facial pain. Aviva said that Miss M had answered this question incorrectly. She answered negatively but the medical records show that she had a history of blurred vision – she had reported this to her GP three months before the policy commenced in November 2024. I don’t find that was an unfair conclusion for Aviva to reach. I say this because I don’t agree that the question is broad and unspecific – I find it was clear. I understand that Miss M answered the way she did because she thought her visual symptoms were part of her longstanding migraine issues. But the question asks specifically about blurred vision. I haven’t disregarded the evidence that Miss M has submitted from GPs at her surgery – but this does confirm a history of blurred vision. I can’t share the commercial underwriting evidence that Aviva has supplied, but I’m satisfied from this evidence that had Miss M answered the question positively, Aviva would have asked further questions. One of these questions would have been have your symptoms worsened or become more frequent over the last three months? As they had, Aviva would have postponed the application until the symptoms had been fully investigated. Accordingly I’m satisfied that the misrepresentation was a qualifying one under CIDRA. Aviva treated the misrepresentation as careless; I find that was fair. There is no suggestion that it was deliberate or reckless. And for completeness I would add that that I fully accept that Miss M was unaware that she had a brain tumour or that this would be the future diagnosis when completing the application. However for the reason given Aviva was entitled to refuse the claim and must return the premium paid. As it has done so I don’t require Aviva to do anything further. I’m very sorry that my decision doesn’t bring Miss M welcome news at this time. My final decision My final decision is that I don’t uphold this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Miss M to accept or reject my decision before 27 April 2026. Lindsey Woloski Ombudsman

-- 2 of 2 --