Not upheld: claim declined - failure to meet policy definition complaint against Liverpool Victoria Financial Services Limited

Decision detail

Summary

Mr M and Mrs M complained that LV unfairly declined a critical illness claim for severe cardiomyopathy made in November 2025, despite Mr M having a significant cardiac condition requiring an ICD device. LV declined the claim because Mr M's ejection fraction measurements (greater than 35%) did not meet the policy definition requiring 35% or less. The ombudsman found that the policy terms were clear and unambiguous, that Mr M's medical evidence did not satisfy the contractual definition, and that LV had acted reasonably in applying the agreed policy terms. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found that the policy definition for severe cardiomyopathy explicitly requires an ejection fraction of 35% or less for at least 6 months when stabilised on therapy. Mr M's medical evidence showed ejection fraction values greater than 35%, meaning he did not meet the contractual definition. While the ombudsman acknowledged Mr M's significant cardiac condition and the distressing nature of requiring an ICD device, the policy terms are clear and unambiguous. The ombudsman noted that insurers are free to decide which conditions they cover and how to define them, and that LV had not acted unreasonably in applying the agreed policy terms.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website