Not upheld: claim declined - failure to meet policy definition of terminal illness complaint against Scottish Friendly Assurance Society Limited

Decision detail

Summary

Mr E purchased a life insurance policy from Scottish Friendly in summer 2023 and was diagnosed with terminal cancer in 2025. He claimed on the policy's terminal illness benefit, but SF declined the claim because while his cancer was incurable, his consultant had not confirmed his life expectancy was less than 12 months as required by the policy definition. The ombudsman upheld SF's decision, finding that both elements of the terminal illness definition must be satisfied and that SF had correctly applied the policy terms. The ombudsman noted that SF would reassess the claim if Mr E's consultant subsequently confirmed a life expectancy of less than 12 months.

The Ombudsman's reasoning

The ombudsman determined that the policy definition of terminal illness contains two cumulative requirements: (1) the illness must be incurable or have progressed beyond cure, and (2) the attending medical specialist must confirm life expectancy of less than 12 months. While Mr E satisfied the first requirement, there was no evidence his oncologist had confirmed the second requirement. The ombudsman could not reword the policy or override its clear terms, and could only assess whether SF had applied the existing terms correctly. SF had done so appropriately.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website