Not upheld: claim declined - related condition exclusion complaint against Canada Life Limited

Decision detail

Summary

Mrs D joined her employer's group critical illness scheme in April 2024 and was diagnosed with multiple sclerosis in September 2024. She submitted a claim which CLL declined on the basis that she had suffered from numbness in her hand in 2022 and 2023, prior to joining the scheme, which constituted a related condition for MS and was therefore excluded from cover. The ombudsman found CLL's decision was fair and reasonable, as the policy clearly documented the numbness as a related condition and the exclusion applied to any related condition existing 'at any time prior to' joining the scheme. The ombudsman upheld CLL's offer of £150 compensation for processing delays but found no grounds to overturn the claim decline.

The Ombudsman's reasoning

The ombudsman found that Mrs D's medical records clearly documented numbness (abnormal sensation) prior to joining the scheme. The policy explicitly states that 'any form of' abnormal sensation is a related condition for MS, and that related conditions 'existed at any time prior to' joining the scheme are excluded. The word 'existed' is defined to include conditions that were 'known to the insured person' - which was clearly the case as Mrs D had consulted her GP about the numbness. The ombudsman rejected Mrs D's argument that the two-year exclusion period limited how far back CLL could look, finding instead that the policy allows CLL to consider any related condition that existed prior to joining, regardless of when it occurred. The £150 compensation for delays was deemed reasonable as CLL operated within the eight-week regulatory timeframe for complaint responses.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website