Aviva Life & Pensions UK Limited · DRN-6151591

The complaint Ms R’s complained that Aviva Life & Pensions UK Limited unfairly declined the claim she made for total and permanent disability. I’m not upholding Ms R’s complaint about Aviva Life & Pensions UK Limited. So I’m not asking Aviva Life & Pensions UK Limited to do anything differently. What happened In 2008, Ms R bought a life and critical illness policy from an insurer I’ll call X. The policy is now administered by Aviva. Ms R served in the armed forces. In 2023, she was medically discharged, and in 2025 was diagnosed as suffering from complex post traumatic stress disorder (CPTSD). So she submitted a critical illness claim to Aviva. The policy didn’t cover CPTSD. So Aviva considered the claim as one for total and permanent disability (TPD). But they declined the claim, because they said Ms R’s policy says that TPD claims would be assessed on her ability to carry out various physical activities – which she could. Ms R complained. She said the policy provided that TPD could be assessed on the basis she couldn’t work in her own occupation – which her CPSTD had stopped her from doing. Aviva explained that the basis of how TPD would be assessed had been set out when the policy started and couldn’t be changed. Ms R didn’t accept Aviva’s resolution and brought her complaint to the Financial Ombudsman Service. She was unhappy that Aviva had based their assessment on her ability to complete various physical functions and failed to recognise that mental health could also be disabling. Investigator’s outcome Our investigator reviewed all the evidence and concluded Aviva didn’t need to do anything different to resolve Ms R’s complaint. He explained that the policy set out two options for how TPD before the age of 65 could be considered. The schedule to the policy states which should apply. And Ms R’s schedule said assessment would be based on an activity definition – not on Ms R’s ability to perform her own occupation. So it was fair for Aviva to assess her as they had. Ms R 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.

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I understand Ms R is unwell. But that, on its own, doesn’t mean I can say her claim should be paid. I have to decide whether it was fair of Aviva not to pay it, by checking the terms and conditions of her policy. Critical illness policies don’t cover every possible illness or condition. They provide cover during the policy term for specific illnesses listed in the policy. That list doesn’t change. Ms R has said her CPTSD should be considered. And she says that Aviva do now offer policies which provide that cover, but she was never offered an “upgrade”. Customers are free to review their cover at any time to decide if it’s still suitable for their needs or if a newer policy will be better for them. But there’s no obligation on insurers to bring newer policies to a customer’s attention. Even if there were, I couldn’t reasonably say Aviva should simply have offered this cover to Ms R. A decision to offer critical illness cover – and at what cost - is always based on medical disclosures at the time a policy is taken out. I couldn’t reasonably say that Aviva should simply have “upgraded” the policy without going through that process. And I can’t say Aviva haven’t considered Ms R’s CPTSD. Her policy doesn’t cover that condition. So Aviva assessed a claim based on the only other option in the policy – whether she met the TPD definition. I think that was fair. I’ve considered the policy definition of TPD. The relevant part says: “The relevant cover Schedule will state the definition of Total and Permanent Disability we will use to assess a claim arising before the person covered's 65th birthday.” It then goes on to provide two options: “Own occupation (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 the essential duties of their own occupation The essential duties of an occupation are those that cannot reasonably be omitted without affecting the ability to carry out that occupation. The disability must be permanent and irreversible. 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 of certain aids. The disability must be permanent and irreversible.” So, while I accept Ms R’s policy does set out two different options for assessing TPD, I’m satisfied it makes it clear that only one definition will be applied – and which that is is shown on the schedule. Ms R’s schedule says: “definition of disability Activity Definition”

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I appreciate Ms R doesn’t meet the activity definition. But that doesn’t mean I can say Aviva should apply the own occupation definition instead. They applied the definition the schedule says they would if a claim were made. And so I don’t think they need to do any more to resolve Ms R’s complaint. My final decision For the reasons I’ve explained, I’m not upholding Ms R’s complaint about Aviva Life & Pensions UK Limited. Under the rules of the Financial Ombudsman Service, I’m required to ask Ms R to accept or reject my decision before 21 April 2026. Helen Stacey Ombudsman

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