Aviva Life & Pensions UK Limited · DRN-6173563

The complaint Miss G complains Aviva Life & Pensions UK Limited (Aviva) has declined the claim she made under an income protection insurance policy. What happened The circumstances of this complaint will be well known to both parties and so I’ve summarised events. Miss G was covered under a group income protection policy through her employer. The policy was underwritten by Aviva. In December 2024 Miss G became absent from work and subsequently was diagnosed with severe mitral regurgitation requiring surgery. A claim was submitted under the policy. Following investigation Aviva declined the claim. It said it believed Miss G’s initial absence was work related. It said it could support an absence from August 2025 until November 2025 due to Miss G’s heart condition, but the policy included a 12 month deferred period. Miss G raised a complaint as she believed her absence from work was solely due to the symptoms of her heart condition. On 28 November 2025 Aviva issued Miss G with a final response to her complaint. It said it thought the evidence showed she stepped away from work before her cardiac issue due to her situation at work. Miss G referred her complaint to this Service. Our Investigator looked into things but didn’t uphold Miss G’s complaint. Miss G didn’t agree with our Investigator’s view. She provided a detailed response but in summary she said: • It wasn’t reasonable to rely on the incorrect diagnosis made by her GP. Her GP’s diagnosis of stress has been superseded by the cardiology evidence. • The log she had provided demonstrated she first started attending her GP in December 2024 complaining of fatigue and exhaustion which are recognised symptoms of her cardiac condition. • Our Investigator had said her attending a gym and swimming were relevant to whether she was able to carry out her occupation. But failed to say her attendance to the gym was part of her prescribed physiotherapy to manage chronic back and knee conditions. As an agreement couldn’t be reached the complaint has been passed to me to decide. 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 want to acknowledge I’ve summarised Miss G’s complaint in less detail than she’s

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presented it. I’ve not commented on every point she has raised. Instead, I’ve focused on what I consider to be the key points I need to think about. I mean no discourtesy by this, but it simply reflects the informal nature of this Service. I assure Miss G and Aviva I’ve read and considered everything that’s been provided. The relevant rules and industry guidelines explain Aviva shouldn’t unreasonably reject a claim. The terms of Miss G’s policy explain benefit will be provided if she meets the policy definition of incapacity. Incapacity is defined in the policy as: ‘The member’s inability to perform on a full and part time basis the duties of their job role as a result of their illness or injury. … Absence caused by workplace matters, such as a relationship breakdown, workplace demands or failure to make reasonable adjustments are not covered.’ The policy also includes a 52 week deferred period. This means Miss G would need to be continuously incapacitated for 52 weeks before any benefit would be paid. The onus is on Miss G to prove her claim. So, she would need to demonstrate, through medical evidence, she met the policy definition of incapacity throughout the deferred period and beyond. Aviva has said it acknowledges Miss G met the policy definition of incapacity for a period following her diagnosis of a cardiac issue and the subsequent surgery she required. However, it considered Miss G’s initial absence to be related to workplace issues rather than due to an illness or injury. Miss G has said her GP incorrectly diagnosed her with workplace stress and her absence was due to the symptoms of her then undiagnosed cardiac issue. Based on the evidence provided, I don’t think it was unreasonable for Aviva to conclude that Miss G’s initial absence from work was related to workplace issues rather than due to symptoms of her illness. In December 2024 her GP notes mention problems with her manager which had been ongoing for a year and recently escalated. In January 2025 the GP notes said that Miss G was unable to return to work due to her ongoing situation with her manager and she was currently job searching. The notes go on to say they discussed potential adaptations, but this wasn’t feasible at present due to ongoing HR investigation. In March 2025 the GP notes state that Miss G felt unsafe to return to work due to the ongoing situation with her manager. They go on to say she didn’t want interaction with a specific colleague and she was currently applying for internal positions within the company. On 30 April 2025 Miss G’s psychologist wrote a letter to Miss G’s GP. In the letter the psychologist has written: ‘Miss G had hoped that her grievance would have been resolved by now and that she would be working in another team at (employer). Regrettably, this has not happened. Miss G feels wholly unable to return to the team managed by the member of staff against whom she has lodged the grievance; she states that this would provoke

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intolerable anxiety.’ I acknowledge within the medical evidence there is mention of Miss G suffering from symptoms such as lethargy and tiredness which Miss G has said dated back to at least December 2024. And I can see her cardiologist has said the symptoms of breathlessness and fatigue she was suffering from in December 2024 were likely due to her cardiac condition and not stress. However, the medical evidence from late December 2024 up until April 2025 is consistent that the reason Miss G felt unable to return to work, wasn’t due to symptoms of a medical condition, diagnosed or otherwise, but was due to workplace related issues, which the policy doesn’t cover. And I don’t think the later evidence from after Miss G was diagnosed with a cardiac issue mean the earlier evidence surrounding Miss G’s workplace related issues must be ignored. Taking all of this into consideration I think Aviva have fairly considered Miss G’s claim, and I think it reasonably concluded that Miss G hadn’t met the policy definition of incapacity throughout the 52 week deferred period. So, I think it was reasonable for it to decline her claim. I’m aware this will be disappointing for Miss G as I know how strongly she feels her absence was solely due to the symptoms of her cardiac condition. However, for the reasons I’ve explained I don’t require Aviva to take any further action in relation to her complaint. My final decision For the reasons I’ve outlined above, I don’t uphold Miss G’s complaint about Aviva Life & Pensions UK Limited. Under the rules of the Financial Ombudsman Service, I’m required to ask Miss G to accept or reject my decision before 31 March 2026. Andrew Clarke Ombudsman

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