Not upheld: claim decline — application of pre-existing conditions exclusion complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Miss M claimed under a group critical illness insurance policy for rheumatoid arthritis diagnosed in May 2023, but Legal and General declined the claim citing a pre-existing conditions exclusion. The exclusion applied because Miss M had experienced symptoms of palindromic rheumatism before joining the policy in August 2021, and this condition was related to her subsequent RA diagnosis. Although Miss M provided additional medical evidence and her consultant stated that progression from palindromic rheumatism to RA is not definite, the ombudsman found that the medical evidence supported the progression occurred in her case and that Legal and General fairly relied on this evidence when maintaining the claim decline. The ombudsman did not uphold the complaint, though acknowledged Legal and General could have been clearer in its communications.

The Ombudsman's reasoning

The ombudsman found that the medical evidence clearly supported that Miss M experienced symptoms of palindromic rheumatism before joining the policy, despite her self-reporting of timeframes potentially being inaccurate. The ombudsman was satisfied it was fair and reasonable for Legal and General to rely on recorded medical information. Critically, the ombudsman found that the medical evidence supported a causal link between the pre-existing palindromic rheumatism symptoms and the subsequent RA diagnosis, as both Miss M's consultant and Legal and General's medical adviser confirmed that palindromic rheumatism can progress to RA. Although Miss M's consultant stated this progression is not definite, the evidence in her case supported that this progression occurred. Therefore, the pre-existing conditions exclusion was fairly applied.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website