Not upheld: claim declined - failure to meet policy definition of terminal illness complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Mr and Mrs L complained that L&G unfairly declined a terminal illness claim following Mrs L's diagnosis with incurable cancer in 2025. The policy defined terminal illness as requiring both an incurable diagnosis and life expectancy of 12 months or less in the opinion of the hospital consultant and L&G's Medical Officer. L&G declined the claim based on a medical report stating 2-3 years life expectancy with treatment. Mr and Mrs L argued the report was unreliable as it was completed by a junior colleague rather than the consultant personally, and that without treatment Mrs L's life expectancy was 6-9 months. The ombudsman found L&G's decision was fair and reasonable, rejecting all of Mr and Mrs L's arguments and finding the medical evidence did not support the 12-month life expectancy criterion required by the policy.

The Ombudsman's reasoning

The ombudsman found that L&G fairly applied the policy terms which require life expectancy of 12 months or less. The medical evidence provided showed 2-3 years life expectancy with treatment, which did not meet this threshold. The ombudsman rejected arguments that the report was unreliable because completed by a junior colleague rather than the consultant personally, as L&G had written to the consultant and there was no evidence the consultant disputed the content. The ombudsman also rejected reliance on the SR1 form and PIP eligibility as these use less specific language ('might' and 'not be surprised') than the policy's requirement for expected death within 12 months. The ombudsman acknowledged Mrs L's statement about 6-9 months life expectancy without treatment but found it reasonable for L&G to consider the impact of ongoing treatment on life expectancy.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website