Health insurance exclusions justified re. ASD

Hello. 

My partner's work enables the family to all use an Aviva health insurance policy. We had to fill in extensive paperwork and I honestly noted that my 10 y/o daughter is diagnosed with ASD. 

Her policy was returned with the exclusion noted: "Any recognised related conditions or complications including any recognised complication of treatment(s) arising from: Autism spectrum disorders and any recognised associated conditions including anxiety, stress, depression or mental disorder including any non-organic functional or somatoform disorder and fatigue syndrome."

I called them on the phone and grilled an underwriter about this as I read this as broadly discriminatory and wanted clear explanation of how they understood ASD and on what basis they made decisions about if ASD was related to any other possible medical problem. They were not able to ask my questions so I requested the pass my concerns to their manager and eventually was sent an email which detailed: 

"Aviva take professional medical advice and as per NHS guidance understand that Autism is not an illness or disease, but something you are born with. It is therefore not classed as an acute medical condition."

But then went on to say, "As Autism is not classed as a medical illness or disease this means that Autism would not be covered under the terms and conditions of your Aviva policy." But that was not my question, I wanted them to justify why ASD, which they explicitly state is not an illness or disease, is grounds for exclusions on my daughter's policy. 

They also noted "Aviva understands and takes its obligations under the Equality Act 2010 seriously, and do not exclude cover generally for people on the basis of their protected characteristic. We are aware that Autism may be classed as a protected characteristic under the Equality Act depending on the impact the condition has on the individual persons day to day activities. The Equality Act allows insurance companies to exclude or limit cover if a pre-existing condition or disability increases the insurance risk". 

The closest they got to answering my question is "If at any time Olive were to suffer from a symptom or condition that could be related to, or caused by, her Autism our Claims Team would seek medical advice from her General Practitioner to understand what symptoms she was suffering from and whether in their medical opinion it was related to her
Autism. Their medical testimony would then be assessed alongside the policy terms and conditions to establish what cover is available under the policy you hold." Which feels pretty unsatisfactory. 

I'd really appreciate a sense check here:

- I think this is inconsistent, in that it says ASD is not a medical condition, but then uses it to justify exclusions
- I don't think they have actually explained the basis on which ASD (already noted as not a medical condition) would be assessed as ir/relevant to any other possible medical problem
- It just feels wildly discriminatory

If so, does anyone have any suggestions about how I should respond, or if there are independent organisations I could go to for further advice/ guidance here?

Thanks all,

  • Dear DebsJ,

    Thank you for sharing this with our community.

    You may be interested in looking at Disability Law Service which might potentially help offer free legal advice to disabled and carers: https://dls.org.uk/?

    Please also be aware of our Community Rule 6: No medical or legal advice. Do not offer medical or legal advice. Always seek professional help for these matters. Treat any medical or legal information shared as the opinion of the user who posted it and meant for general discussion purposes only. 

    Thank you. I hope this helps.

    With all good wishes,

    Eunice Mod

  • I just noticed that, thankfully, it’s now been reinstated from quarantine. 

  • Insurance companies are allowed to make decisions based on "risk". If a person with a particular disability is more likely to claim, then they can set higher premiums or decline cover based on that disability. So, it is not necessarily discriminatory to consider autism as a factor in what cover they're prepared to offer. This article explains it well and supports your request for more detailed information from the insurer:

    https://www.mind.org.uk/information-support/guides-to-support-and-services/insurance-cover-and-mental-health/your-insurance-rights/

    I would be more concerned about their reliance on a GP's opinion.

    I don't think a GP could ever be considered qualified to say whether a medical condition is *definitely* related to a patient's autism. They aren't specialists in autism and, by and large, they don't spend any time getting to know their patients as individuals either.

    There are lots of conditions that you are more likely to have if you're autistic (e.g. asthma, food allergies or epilepsy), but it doesn't mean they're all "related" to autism in a causal sense.

    I think you're right to ask for more clarity about what they mean and I think you should pursue a complaint until you get it, up to the Financial Ombudsman Service if necessary (FOS is free and will give an independent view).

  • I think this is inconsistent, in that it says ASD is not a medical condition, but then uses it to justify exclusions

    Technically it is a developmental disorder but the end results are similar to a condition which is why they probably lump it under this heading.

    Any insurance policy will normally exclude pre-existing conditions so since the disorder of autism is pre-existing they are treating it in the same way.

    This is all quite standard practice for insurance companies and I don't think it breaks any laws as it is laid out and you choose to accept it or not.

    It just feels wildly discriminatory

    No more than it would discriminate against not covering someone someone with a recently broken leg from it breaking again - their title "we do not cover pre-existing stuff" is their business model to avoid predicatable high risk situaitons.

    If your daughter has a risk of having a meltdown, running away and being hospitalised because she appears hysterical is one predictable risk they will see, so they won't cover it.

    I really doublt you have any legal grounds to take them to task for it - maybe best to find an insurer who will cover her for the things you want - you probably would need to be specific in the asking of the questions though.

  • It isn’t your fault. The ‘edit’ and ‘delete’ are too close together on my iPad and I could have accidentally clicked on ‘delete’. I can zoom in on the iPad to see things better but then I lose so much of the page content that I tend not to do that. 

  • Oh no! It will have gone to the moderation queue.

    That can happen sometimes when we edit posts, but I wouldn’t have expected it in response to a single edit like that one. The forum’s spam filter remains as mysterious in its ways as ever, it seems! I’m so sorry, I really didn’t think that was likely to happen at all. 

  • Thanks, I have just tried that and my post has disappeared.

  • could I just point out my typo

    It happens to us all! Slight smile

    If you tap or click on “More” beneath your original post, the Edit option will be shown.

    I’ve had to correct many, many typos of my own! :)

  • You are probably right Bunny and could I just point out my typo, I am not a legal person.

  • The last paragraph has typos. It should say “I agree … but I am not a legal person”

  • They have a choice to insure you or not, and if they do then usually always with limitations at which you point you decide whether to accept them or not.  To me their exclusions seem reasonable and pretty sure such a large firm would have this already legally checked out.

    Personally think you'd be fine in most likely instances but not absolutely everything, which you seem to expect.

  • The closest they got to answering my question is "If at any time Olive were to suffer from a symptom or condition that could be related to, or caused by, her Autism

    All I’ll say is that my immediate reaction was to recall that the NAS, just for example, have published an article in which they list what they describe as some “related conditions”:

    https://www.autism.org.uk/advice-and-guidance/topics/related-conditions/related-conditions/all-audiences

    I feel this is very much a matter that you should seek legal advice on, rather than being steered in any particular direction by anyone here. There also wouldn’t seem to be much point, in my view, in complaining to, say, your MP unless and until you know where you stand from a legal perspective. 

  • I think that companies like Aviva would be difficult to challenge and you may need to take a long term approach without expectation of a fast resolution. 

    The closest they got to answering my question is "If at any time Olive were to suffer from a symptom or condition that could be related to, or caused by, her Autism our Claims Team would seek medical advice from her General Practitioner to understand what symptoms she was suffering from and whether in their medical opinion it was related to her
    Autism. Their medical testimony would then be assessed alongside the policy terms and conditions to establish what cover is available under the policy you hold." Which feels pretty unsatisfactory

    It might be worth asking Aviva if they could give you several hypothetical symptoms or conditions as it is far from clear how this could be interpreted. 

    You could also try Citizens Advice, or search for an insurance ombudsman or similar which should be listed the small print on your insurance document, and complain that the policy is not worded in an understandable format.

    I agree that Aviva’s response seems discriminatory but I am not a legal person so I don’t know. Maybe you could ask your MP to get involved.

  • I think they are trying to say that ASD alone isn't a medical condition, but when added to conditions can/could compound difficulties- and so clarification would be required from the GP on a case by case basis.  That is my understanding.

    Did someone's ASD accentuate matters in a particular scenario?  Would the impact or severity have been more/less had the person not had ASD?   

    The issue then becomes even more complicated because a GP isn't usually the best placed person to judge the effects of ASD anyway.  But that's their rules, and that's what they are working to.  

    I am not sure this is discriminatory because they are making you aware beforehand of the situation and not stipulating that it negates cover at all, but to say one way or another verges on legal advice, and we can't give that on this forum.   


  • Well I guess you could try emailing this site and asking for help, thats one of the sorts of things they're supposed to be here for.

    If you have any sort of social worker they might be able to help?

    You could try writing to your MP and the equalities minister.

    You could also try asking in the consumer pages of somewhere like the Guardian newspaper, I thin this is just the sort of thing they'd get thier teeth into.

    Trouble is insurance companies can pretty much write thier own rules and as anyone who's ever had to wait for a pay out especially on car insurance they will do everything they can to minimise thier pay out or not pay at all.

    I agree it doe's seem discriminatory and they've not really fiven you an answer, I wonder if, heavens forbid, your daughter had or saw something traumatic and needed counselling to come to terms with it would this be covered or would they try and say that her trauma was autism related, rather than something anybody would be affected by?

    If she had something physical would they exclude her because of autism?