Not upheld: non-disclosure of medical history; claim decline; policy unwinding complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Miss M and Mr B complained that L&G unfairly declined Miss M's critical illness claim and unwound their joint policy due to non-disclosure of her medical history. Miss M argued that L&G should have identified her neurological issues during its initial GP checks at application. The ombudsman found that L&G asked clear questions about neurological symptoms, and Miss M's medical records showed she had consulted neurologists and experienced relevant symptoms (facial pain, dizziness, balance problems, vision issues) within the five years before the August 2023 policy inception. The ombudsman concluded Miss M should have answered 'yes' to these questions, constituting a careless misrepresentation. Under CIDRA, L&G was entitled to decline the claim, unwind the policy, and refund premiums, which the ombudsman found to be fair and consistent with the law.

The Ombudsman's reasoning

The ombudsman found that L&G asked clear, plain language questions about Miss M's medical history. Miss M's medical records showed she had consulted neurologists and suffered neurological symptoms (facial pain, vertigo, dizziness, balance problems, blurred and double vision) within the five years preceding the policy's inception. The ombudsman concluded Miss M should have answered 'yes' to the neurological symptoms question. This constituted a careless misrepresentation under CIDRA. The ombudsman rejected Miss M's argument that L&G should have identified the issues during its initial checks, finding that this did not excuse Miss M's duty to provide accurate answers. L&G's remedial actions (declining the claim, unwinding the policy, and refunding premiums) were consistent with CIDRA's available remedies.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website