DRN-6207486

The complaint Mr and Mrs C are unhappy with Aviva Life & Pensions UK Limited’s decision to decline Mrs C’s claim. What happened Mr and Mrs C have joint life and critical illness cover with Aviva. Mrs C made a claim for total and permanent disability (TPD) following her diagnosis of complex post-traumatic stress disorder (c PTSD). Mrs C also suffers with depressive disorder, disassociation, derealisation and depersonalisation. In March 2025, Mr and Mrs C sent Aviva their claim form, which was declined three-months later in June. Mr and Mrs C disagreed with Aviva’s reasons for declining the claim. They said Mrs C’s symptoms are so severe that she was medically retired from work and is incapable of working in the future because of her medical conditions. They also said Aviva’s processes and communications have been poor and difficult to navigate and that the insurer wouldn’t send them a claim form when asked in November 2024. Aviva said it declined the claim because Mr and Mrs C hadn’t met the policy terms. It said Mrs C must evidence she’s unable to complete three out of the seven activities of daily work tasks, as defined by the policy. It acknowledged she has difficulty with some of the tasks, including walking and communicating, but said this isn’t on a permanent basis. It maintained its decision to decline the claim. Our investigator didn’t uphold this complaint. He said the medical evidence didn’t support Mrs C was permanently unable to complete any three of the activities of daily work tasks. He also acknowledged Mr and Mrs C’s concerns about the policy not providing a definition of ‘total’ but didn’t think that had a material bearing on the outcome of this complaint. Mr and Mrs C, unhappy with this, asked for an ombudsman to review their complaint. In summary, they said Aviva’s chief medical officer made mistakes in his assessment of Mrs C’s medical evidence and therefore his testimony is unreliable in the circumstances. They also said the nature of Mrs C’s condition is such that she doesn’t experience continuous symptoms, rather, the fluctuating nature of her symptoms mean that she’s totally and permanently disabled. Mr and Mrs C said it’s unrealistic to expect that she suffers continually throughout the day. They argue Aviva’s strict interpretation of the policy terms mean Mrs C would never be able to bring a valid claim for her illness. And so, it’s now for me 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.

-- 1 of 5 --

Having done so, I’ve decided not to uphold it and for broadly similar reasons to those given by our investigator and I’ll go on to explain why. Although I may not respond to every point Mr and Mrs C have raised, I want to reassure them I’ve considered everything they’ve said. The informal nature of this service enables me to do that so I can resolve complaints with minimal formality. I sympathise with Mrs C regarding the very difficult personal circumstances she’s experienced and want her to know I’m in no way minimising the seriousness and severity of her symptoms. It sounds as though she’s been through some very traumatic events which have caused her mental health conditions. The relevant rule that applies in this case comes from the Insurance Conduct of Business Sourcebook (ICOBS) and says Aviva must assess claims promptly and fairly and must not reject a claim unreasonably. I’ve considered this and other relevant industry guidance whilst assessing Mr and Mrs C’s complaint. The key consideration here is the policy terms as they define the basis upon which Aviva considers Mrs C to be totally and permanently disabled. Whilst I accept other organisations, like the Department for Work and Pensions, have a different criterion for assessing claims, it’s Aviva’s own policy that applies in this case. The bar set by insurers for TPD claims is generally higher than government-backed schemes. The policy terms say about TPD: The definition for ‘Activities of Daily Work’ are: “Activities of Daily Work (to 65th birthday) The person covered will be regarded as being totally and permanently disabled, if, because of any injury or illness, they are unable to perform any three Activities of Daily Work, without the direct assistance of another person, but with the use, where appropriate of certain aids. The disability must be permanent and irreversible” The Activities of Daily Work are: “Walking – The ability to walk a distance of 200 metres on flat ground without stopping or experiencing severe discomfort. Climbing – The ability to walk up or down a flight of 12 stairs without holding onto a rail or resting. Bending – The ability to bend or kneel to pick up something from the floor and stand up again and the ability to get into and out of a standard saloon car. Communicating – The ability to answer the telephone and take a simple message. Eyesight – Having eyesight, after correction if required, sufficient to read 16 point print. Healthcare – Having the ability to independently make arrangements, when necessary, to seek medical attention and take medication as prescribed. Financial Independence – The ability to handle routine day to day financial transactions.” Permanent is defined in the policy as: “Permanent means a condition that is expected to last for the remainder of the life of the person covered” Irreversible is defined in the policy as: “Irreversible means a condition that cannot be cured through medical and/or surgical treatment used by the NHS”

-- 2 of 5 --

‘Total’ isn’t specifically defined in the policy. In Aviva’s final response letter in September 2025, it said: “The definition of total is a commonly understood word and in the context of this policy means absolute/complete” I’ve highlighted these terms because this is the test Mrs C must satisfy to show she has a valid TPD claim under this policy. I’ve reviewed the available medical evidence provided by Mr and Mrs C and Aviva’s CMO. Having taken everything into account, I’m persuaded Aviva’s interpretation of the evidence is fair and therefore it can reasonably decline the claim on the basis Mr and Mrs C haven’t persuasively shown Mrs C is unable to complete three of the seven tasks on a permanent basis. I say that because: • Whilst Mrs C experiences difficulties walking, the evidence from her psychiatrist says this is limited to her symptoms being exacerbated whilst she’s outside. Mrs C’s feelings of being overwhelmed, panicked and hyperarousal/hypervigilance are triggered when she leaves her home. The policy doesn’t make that distinction. It simply says Mrs C must be unable to walk 200 meters on flat ground without stopping or experiencing severe discomfort. And as there’s no evidence that explicitly states Mrs C is unable to achieve that expectation, I think Aviva can reasonably argue she doesn’t meet the criteria for this activity. There’s evidence from Mrs C’s specialist that says she’s prone to falling over when outside because of her symptoms, but that still doesn’t satisfy the policy’s definition. • There’s no medical evidence to support Mrs C experiences difficulty climbing, bending or issues with her eyesight. Whilst Mr C has made arguments to the contrary, this isn’t appropriately or persuasively reasoned by a suitably qualified medical professional. The evidence provided by Mrs C’s specialist says whilst he’s not completed any formal testing for these activities, he didn’t notice Mrs C demonstrate any issues completing these tasks. • In terms of communication, Mr and Mrs C argue that Mrs C has difficulty with comprehension and following instructions. This is supported by medical evidence which, in summary, says Mrs C struggles with communication when experiencing her symptoms of complex PTSD. They also said Mrs C is experiencing issues with her healthcare (as described by the above term). Mr C must administer Mrs C’s medication as her reported memory issues make it difficult to manage on her own. Her consultant explained this could be related to her symptoms of disassociation and derealisation, so I think there is some evidence to suggest she meets this criteria. • Mr and Mrs C provided additional medical evidence from Mrs C’s treating psychiatrist in January 2026. This letter sets out in more detail the difficulties Mrs C experiences with communication and managing her healthcare, however, I’ve not relied on this evidence as part of my final decision. Our investigator already explained this assessment took place after Aviva issued its final response in September 2025 and so I’m unable to consider it. Aviva has been provided with this evidence, and I understand it’s considering it separately from this complaint. I understand Mr and Mrs C’s frustration that I cannot refer to this as part of my decision as they feel it simply consolidates and explains Mrs C’s symptoms more clearly. And whilst that may be the case, it also provides new insight that was previously unsupported by objective medical testimony. Therefore, process dictates Aviva must be given the opportunity to review it independently as it was previously unavailable at the time it issued its final response. Should Mr and Mrs C receive an answer from Aviva they’re unhappy

-- 3 of 5 --

with, they can bring a separate complaint about that. • Mr C explained he’s responsible for all decisions related to financial matters on behalf of Mrs C. He explained Mrs C is unable to recall where money is spent and often forgets to pay bills and so this is an area he takes responsibility for. Aviva argued this is a preference and not an arrangement borne of a legal requirement. Its CMO noted Mrs C isn’t subject to a court order whereby Mr C is compelled to take responsibility for financial decisions. I understand the connection Aviva’s attempting to make here, but its policy terms don’t state that as a requirement of the criteria. I accept a legal order is one way to evidence a loss of independence, but evidence from a suitably qualified medical specialist would be equally persuasive. Based on the available medical evidence, there isn’t anything to support Mr and Mrs C’s argument here and so whilst I accept their testimony at face value, I’d expect to see more evidence to show Mrs C’s poor mental health is so severe, she’s lost her financial independence. Having considered the medical evidence and testimonies of Mr and Mrs C and Aviva, I’m satisfied Aviva declined Mrs C’s TPD claim fairly because the policy terms currently haven’t been met. I should say this my final decision up until the point Aviva issued its final response on this complaint. I’m aware more medical evidence has been sought by Mr and Mrs C which hasn’t been considered as part of this complaint. I also note Aviva’s comments that at this time, Mrs C doesn’t satisfy the TPD criteria, but that this could change should her illnesses progress. I think this shows Aviva has assessed the claim fairly and that it’s relied on medical evidence to reach its outcome on her claim. Mr and Mrs C said Aviva has applied a rigid interpretation of the policy terms, in particular, the need for Mrs C to experience her symptoms of complex PTSD at every moment in order to bring a successful claim. I understand the argument they’re making, but I don’t think that’s entirely accurate. It’s expected that Mrs C must show her symptoms are permanent as that’s the bar she must meet to receive benefit under this policy. As things currently stand, the specialists responsible for Mrs C’s care have recommended she undertake further treatment for her symptoms. I’ve seen she previously underwent CBT, EDMR with grounding and distraction techniques, however, Mrs C said this made her symptoms worse. It was therefore decided Mrs C needed a break to achieve a period of stabilisation, with the view to returning to treatment. It’s therefore evident Mrs C’s treatment pathway remains active and when she’s exhausted the clinical options recommended, it may be that she can she satisfy the permanency element of the policy. Mr and Mrs C also complained Aviva didn’t send a claim form in good time. Having reviewed Aviva’s case handling notes, I saw there was an issue at the beginning of the claims journey. Mr C called to make a claim on 11 November 2024, and the claim form wasn’t sent until a month later on 12 December. The reason for the delay was that Aviva was unsure on what terms the claim should be assessed against. Mr and Mrs C’s policy was incepted with a different insurer and was later taken on by Aviva. So, there was a slight delay whilst Aviva sourced the necessary details so it could assess the claim against the correct terms. And I think that was reasonable. I saw Mr C called again on 18 December to say he’d still not received the claim form. Aviva realised it’d sent the pack to an old address and so apologised and resent it. Mr and Mrs C’s completed claim form was received by Aviva, three months later in March 2025, which was the same month it was signed by Mrs C. So, whilst there was a delay, I couldn’t reasonably hold Aviva responsible for that. Mr and Mrs C also raised that Aviva incorrectly referred to Mrs C’s illness as PTSD, rather

-- 4 of 5 --

than complex PTSD. I saw that happened when Aviva issued its claims decision in June 2025, however, this was acknowledged in its final response in September 2025. Aviva also reassured Mr and Mrs C its CMO had correctly referred to Mrs C’s condition as complex PTSD. I don’t consider that mistake to have had any impact on the overall outcome of the claim. I say that because Aviva assessed Mrs C’s reported symptoms, rather than the name of her illness, against the activities of daily working as defined by the policy. My final decision For the reasons I’ve explained, I don’t uphold this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mrs C and Mr C to accept or reject my decision before 19 May 2026. Scott Slade Ombudsman

-- 5 of 5 --