Not upheld: misrepresentation in insurance application and unfair claim decline complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Mrs F, as executor of her late husband Mr F's estate, complained that L&G unfairly declined a life insurance claim and voided the policy based on alleged misrepresentation of alcohol consumption. Mr F had declared drinking 4 alcoholic drinks per week in his 2020 application, but medical records from months later showed he was drinking 4-5 pints daily and had a fatty liver, progressing to cirrhosis which caused his death. L&G's Chief Medical Officer opined that such liver damage could only result from years of sustained heavy drinking, not the declared amount. The ombudsman found this constituted a qualifying misrepresentation under CIDRA and that L&G complied with the law by declining the claim and returning premiums, so the complaint was not upheld.

The Ombudsman's reasoning

The ombudsman applied the Consumer Information (Disclosure and Representations) Act 2012 (CIDRA), which requires consumers to take reasonable care not to misrepresent material facts. The ombudsman found that L&G's Chief Medical Officer provided credible expert evidence that Mr F's liver damage (fatty liver and cirrhosis) could only have resulted from years of sustained heavy alcohol consumption, not the 4 drinks per week declared. The ombudsman was more persuaded by the CMO's medical opinion than by Mrs F's alternative explanations. The ombudsman found this constituted a qualifying misrepresentation (as L&G would not have offered the policy if accurate information had been provided) and that L&G complied with CIDRA by declining the claim and returning premiums.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website