I have been an Aviva life insurance customer for ten years. I advised them two years ago I had been diagnosed with terminal cancer.
I was put on a drug which stopped the cancer growing and kept me alive. Now that treatment has ended. I told my insurance company immediately of my diagnosis.
I recently made a claim after my consultant informed Aviva I had less than 12 months to live.
However, Aviva have declined the claim because my policy ends in May 2022 so, if the doctor is right, I will likely die about 12 weeks after that. Is this fair?
An Aviva customer had her claim rejected despite being diagnosed with terminal cancer
Grace Gausden, This is Money, replies: Firstly, I am incredibly sorry to hear about your diagnosis.
Unfortunately, your consultant has advised you will likely have less than 12 months to live after stopping the cancer treatment that was keeping you alive.
As a result, you made a claim with Aviva under your life insurance policy but were frustrated to find out it was refused.
Aviva said that as your policy is due to come to an end in May 2022, and it is thought you will likely pass away within a couple of months after that date, it cannot pay you.
This is also despite, over the course of ten years, you paying £12,670 towards your life insurance policy.
Usually, Aviva’s life insurance plan pays out a cash lump sum to a policy holder if they pass away or are diagnosed with a terminal illness where they are not expected to live longer than 12 months.
However, the insurer rejected your claim, saying a claim cannot be made for Terminal Illness benefit in the 12 months before the policy ends.
The Terminal Illness benefit allows the customer to receive a life insurance payment early, if a medical specialist confirms they are sadly expected to live for less than 12 months.
This is an acceleration of the death benefit and enables customers to put their affairs in order, rather than it being paid to the beneficiaries after death.
Aviva added the decision to decline the claim was based on a review by its Consulting Medical Officer of the latest medical information the hospital had supplied it with and the review concluded that your life expectancy could not be said to be less than 12 months due to the success of your immunotherapy treatment.
However, you raised concerns that your medical records were not sent over until September of this year, when they should have been sent in November of last year, due to delays caused by the pandemic.
Aviva has said the customer is not eligible for a pay-out under her policy after reviewing it
In the months between when the records were sent and when they were received, your condition has changed dramatically and you’re concerned that Aviva is not acknowledging this.
The insurer will also not let you renew or extend your policy, leaving you with few options.
However, Aviva says it has valid reasons for not accepting the claim which it outlines below.
An Aviva spokesperson replies: We are very sympathetic to the customers’ situation.
Her life insurance policy has a terminal illness benefit which is payable when, in the opinion of an attending consultant and our Consulting Medical Officer, there is unfortunately a life expectancy of less than 12 months.
In reviewing the claim our Consulting Medical Officer and a separate Professor in Oncology have independently assessed all of the customers’ medical information to understand the impact that her targeted immunotherapy treatment has had on her condition.
They note that she has received the immunotherapy treatment for the optimal two year period to build resilience to the disease and this treatment completed in October.
In considering this claim, we have reviewed medical data which shows that more than 80 per cent of patients receiving this optimum level of treatment are alive 3 years after completing treatment.
Both experts independently report that her medical information shows she has clear evidence of an excellent response to the immunotherapy and there is a very good likelihood of long-term disease control, so the criteria for a terminal illness benefit claim has not been met.
Based upon the medical data and the customers response to treatment it’s highly likely life expectancy will be several years. Her policy will now continue to provide life cover only until the end of the policy term.
We have reviewed this case extremely thoroughly as we understand such cases are very difficult, where there is a terminal diagnosis but where the prognosis for survival does not meet the criteria for a claim.
However, we have a duty to all our customers to assess each claim against the policy conditions for that customer.
Customers who do not agree with their insurers decision can take a claim to the Ombudsman
Grace Gausden, This is Money, adds: Unfortunately as Aviva claim there is ambiguity with regards to your medical treatment, it has said it will not pay-out, despite reviewing your circumstances.
It has explained its reasons for doing so, advising that, despite your illness, it has to follow the guidance it has been given.
However, it is possible to now take the issue to the Financial Ombudsman who can review the case and decide whether it believes Aviva has acted fairly or not.
The final decision given at the end of this investigation will be binding on them but if you do not agree with it, you can take your insurer to court.
In your case, while you disagree with the decision, these processes may sadly not be the best option due to the time and effort it can take to follow them through.
It does serve as a warning to others who take out insurance policies to read the terms and conditions carefully in case a circumstance like this does happen.
Customers with any concerns should contact their insurer directly to clarify any clauses they are unsure of.