Aviva Health Insurance Claim Denied: How to Appeal in the UK

Aviva Health Insurance Claim Denied: How to Appeal in the UK

Aviva is the UK's largest general insurer and one of the leading providers of private medical insurance (PMI), life insurance, critical illness cover, and income protection. With over 19 million customers in the UK, Aviva handles millions of insurance claims each year — and when they deny a claim, policyholders have robust legal rights to challenge that decision.

If Aviva has denied your health, life, critical illness, or income protection claim, this guide explains every step you can take to fight back.

About Aviva's Insurance Products

Aviva offers:

• Aviva Health — private medical insurance for individuals, families, and businesses
• Life insurance — term life, whole of life, and over 50s plans
• Critical illness cover — lump sum payout on diagnosis of specified conditions
• Income protection — monthly income replacement for long-term illness or disability
• Group risk — employer-sponsored life, critical illness, and income protection
• Car, home, and travel insurance

Common Aviva Denial Reasons

Pre-existing condition exclusions (PMI): Aviva PMI policies commonly exclude:

• Conditions you had before the policy started
• Conditions arising during a moratorium period
• Conditions explicitly listed as exclusions under full medical underwriting

Medical necessity disputes (PMI): Aviva may deny treatment it considers not clinically necessary based on its own clinical criteria.

Non-disclosure allegations (life/CIC/income protection): Aviva may claim you failed to disclose medical history, lifestyle information (smoking, weight, hazardous activities), or other material facts when applying for the policy. Under CIDRA (for policies from April 2013), deliberate or reckless non-disclosure can void the policy; innocent non-disclosure requires only a proportionate remedy.

Critical illness definition disputes: Aviva's CIC policies define each covered condition precisely. The most common disputes involve:

• Cancer diagnoses that don't meet Aviva's specific staging or histological criteria
• Heart attacks that don't meet the ECG/enzyme diagnostic thresholds in the policy
• Strokes where symptoms resolved too quickly to meet Aviva's severity definition
• Conditions listed under "additional payment" cover vs. the full lump sum conditions

Income protection disputes: Aviva may challenge:

• Whether your condition meets the policy's definition of disability
• Whether you are capable of performing your own or any occupation
• Whether a pre-existing condition exclusion applies

Car and home insurance disputes:

• Fault attribution disputes
• Valuation disputes for total loss
• Exclusions for policy conditions not met (e.g., home left unoccupied)

Your UK Rights When Aviva Denies a Claim

FCA regulation: Aviva is regulated by the FCA and PRA. FCA rules require Aviva to handle complaints fairly, promptly, and consistently.

Financial Ombudsman Service (FOS): After exhausting Aviva's internal complaints process, you have the right to a free, independent review by the FOS. FOS decisions are binding on Aviva.

Consumer Insurance Act 2012 and Insurance Act 2015: These laws govern Aviva's rights in cases of alleged non-disclosure and misrepresentation.

Step-by-Step: How to Appeal an Aviva Denial

Step 1: Obtain Aviva's Written Denial with Full Reasons

Request a full written explanation from Aviva stating:

• The specific policy clause applied
• The factual basis for the denial
• Any evidence they relied on (medical reports, surveillance, etc.)
• Your right to complain and the FOS

Step 2: Review Your Policy Wording Carefully

Aviva's policy documents are long and technical. The key sections to review:

• The Definitions section (for critical illness, income protection)
• The Exclusions section
• The Conditions and Claims conditions sections
• The Moratorium or Underwriting terms section (for PMI)

If Aviva's interpretation of the policy wording is strained or unfair, this is a strong basis for an FOS complaint.

Step 3: Gather Medical and Other Evidence

For protection claims (life, CIC, income protection):

• Full GP records and hospital records
• Treating specialist letter addressing Aviva's specific denial grounds
• For non-disclosure disputes: GP records and letters confirming what you knew about your health at application
• For critical illness: specialist letter confirming your diagnosis meets or should meet the policy definition; consider independent specialist opinion

For PMI claims:

• Treating consultant letter on clinical necessity
• GP letter on medical history and symptom timeline
• NICE guidelines or professional body guidelines supporting treatment

For general insurance claims:

• Photographs, police reports, witness statements
• Independent valuations
• Surveyor or contractor reports

Step 4: File a Formal Complaint with Aviva

Aviva Customer Relations:

• Phone: 0800 051 0234 (health claims) or 0345 030 7154 (life/protection)
• Online: aviva.co.uk/help/complaints
• Post: Aviva, PO Box 7684, Peterborough, PE3 8YY

State clearly this is a formal complaint. Include all supporting evidence and the specific outcome requested.

Aviva must:

• Acknowledge your complaint within 5 business days
• Issue a Final Response within 8 weeks (or sooner)

Step 5: Escalate to the Financial Ombudsman Service (FOS)

After Aviva's Final Response (or after 8 weeks):

FOS Contact:

• Online: financial-ombudsman.org.uk
• Phone: 0800 023 4567 (free)
• Deadline: Within 6 months of Aviva's Final Response

The FOS is particularly effective for Aviva CIC definition disputes and non-disclosure proportionality disputes.

Step 6: Consider Expert Legal Advice

For large protection claims (life insurance, income protection), specialist insurance dispute solicitors can provide expert advice and representation. Many work on conditional fee arrangements.

Aviva-Specific Tips

Critical illness: use Aviva's own definitions strictly and in your favour: Aviva's CIC policy documents include highly detailed clinical definitions. For borderline cases, engage a specialist (cardiologist, oncologist, neurologist) to provide a formal opinion specifically cross-referencing your clinical findings against Aviva's policy definitions.

Income protection: 'own occupation' standard: Aviva offers various income protection policies, some with "own occupation" definitions, others with "any occupation" or "activities of daily work" definitions. Know which definition applies to your policy. "Own occupation" is the most favourable for claimants.

PMI: always pre-authorise: Aviva PMI requires pre-authorisation for planned admissions and most specialist consultations. Without pre-authorisation, you have limited grounds to dispute a denial based on the absence of approval.

Group scheme members: If your Aviva cover is through your employer's group scheme, speak to your HR team — some group scheme disputes can be escalated through the employer-insurer relationship rather than (or in addition to) the FOS.

Conclusion

Aviva is the UK's largest general insurer, and its scale means its claims processes can feel impersonal and final. They are not. Whether you are challenging a critical illness definition decision, a non-disclosure allegation, or a PMI pre-existing condition exclusion, you have the right to a formal complaints process and an independent FOS review. Use ClaimBack at claimback.app to generate a professional appeal letter for your Aviva insurance dispute.

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Related Reading:

• AXA Health (PPP) Claim Denied: How to Appeal in the UK
• Vitality Health Claim Denied: How to Appeal in the UK
• Legal & General Claim Denied: How to Appeal in the UK
• Critical Illness Insurance Claim Denied: Your Rights