Not upheld: unfair claim decline complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Mr and Mrs W claimed on their critical illness insurance policies with L&G following Mr W's cardiac episode in spring 2025, which resulted in a diagnosis of cardiomyopathy and implantation of an ICD. L&G declined the claim on the basis that Mr W's condition did not meet the policy definitions for either cardiomyopathy (which required evidence of specific functional impairment) or cardiac arrest (which required unconsciousness and resuscitation). The ombudsman upheld L&G's decision, finding that the policy definitions contained specific criteria that Mr W had not satisfied and that L&G was entitled to apply these terms consistently across all claims.

The Ombudsman's reasoning

The ombudsman found that the policy definitions for both cardiomyopathy and cardiac arrest contained specific criteria that Mr W did not fully meet. For cardiomyopathy, the definition required clinical impairment resulting in permanent loss of ability to perform physical activities to at least NYHA Class 3, and Mr W did not provide evidence of this. For cardiac arrest, the definition explicitly required sudden loss of heart function with unconsciousness and resuscitation, neither of which occurred. The ombudsman concluded that L&G must apply policy definitions consistently across all claims and cannot be said to have acted unreasonably by declining the claim when the policy terms were not met.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website