Not upheld: Travel / life insurance claim disputes complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Mr and Mrs T complained that Legal and General unfairly declined a critical illness claim following Mr T's hospital admission for cardiac symptoms. Legal and General declined the claim because the policy definition of heart attack was not met, specifically because new characteristic electrocardiographic changes were not present, despite Mr T's treating team diagnosing NSTEMI. The ombudsman found the decline was fair based on the strict policy terms and medical evidence, noting that although another insurer paid a claim and updated industry guidance existed, it was reasonable to apply the original policy terms and not apply new guidance retrospectively. The ombudsman upheld the £350 compensation for poor service but did not uphold the complaint regarding the claim decline.

The Ombudsman's reasoning

The ombudsman found that Legal and General reasonably declined the claim because the policy definition of heart attack was not fully met. Specifically, the policy required new characteristic electrocardiographic changes, which were not present in the medical evidence. Although Mr T's treating team diagnosed an NSTEMI and another insurer paid a claim, the ombudsman considered it fair for Legal and General to apply their specific policy terms strictly. The updated industry guidance was not applicable as it was introduced many years after the policy inception. The £350 compensation for poor service was deemed fair.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website