Not upheld: terminal illness claim declined complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Mr and Mrs P claimed terminal illness benefit following Mrs P's diagnosis of metastatic inflammatory breast cancer. L&G declined the claim because, although Mrs P's life expectancy without treatment would be less than 12 months, her active treatment extends her life expectancy beyond 12 months, failing to meet the policy definition. The ombudsman found L&G's decision fair and reasonable, as the policy requires life expectancy to be no greater than 12 months and Mrs P's individual circumstances, including her treatment, must be considered. The CMO's assessment, supported by medical literature showing 24-30 month survival with multimodal therapy, was not contradicted by Mrs P's treating specialists. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that the policy definition of terminal illness requires life expectancy to be no greater than 12 months. Mrs P's individual circumstances, including her active treatment, are relevant to determining life expectancy. The CMO's medical opinion, supported by published data showing likely survival of 24-30 months with treatment, was reasonable and not contradicted by Mrs P's treating specialists. Therefore, L&G could fairly decline the claim as Mrs P's life expectancy with treatment exceeds the 12-month threshold.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website