Not upheld: claim declined - failure to meet policy definition complaint against Royal London Mutual Insurance Society Limited, trading as Scottish Provident

Decision detail

Summary

Mrs J claimed on her critical illness policy following a traumatic brain injury in 2021 that left her with significant ongoing health issues and unable to work. SP declined the claim as the policy did not cover brain injuries and Mrs J did not meet the total permanent disability definition requiring inability to perform any 2 of 5 functional ability tests. The ombudsman found SP's assessment reasonable, as while Mrs J clearly struggles with all the tests, the evidence showed difficulties and limitations rather than complete inability to perform them. The complaint was not upheld, though the ombudsman noted SP should reassess if Mrs J's condition deteriorates further.

The Ombudsman's reasoning

The ombudsman found that SP reasonably applied the policy terms. The policy definition of TPD requires the policyholder to be 'unable' to perform any 2 of the 5 functional ability tests, which the ombudsman interpreted as meaning the tasks cannot be performed at all. While Mrs J clearly struggles significantly with all the tests, the evidence demonstrates difficulties and limitations rather than complete inability to perform them. Therefore, SP's conclusion that she did not meet the criteria was reasonable and fair.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website