Not upheld: Travel / life insurance claim disputes complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Mr G, unable to work since 2019 due to a debilitating condition, claimed Total and Permanent Disability benefit under his Term Assurance and Critical Illness Cover policy with Legal and General. L&G declined the claim after noting that a Consultant Neurosurgeon had recommended a CT guided injection treatment that could potentially improve Mr G's symptoms, and an Occupational Therapist had also identified available treatment options. Although Mr G declined the recommended treatment due to risk concerns and chose medication instead, the ombudsman found L&G's position fair because the policy requires permanent disability with no prospect of improvement, and the availability of a potential treatment meant this threshold was not met. The ombudsman upheld L&G's offer of £200 compensation for delays but made no further award.

The Ombudsman's reasoning

The ombudsman found that L&G's decline was fair because the policy sets a high bar requiring permanent loss of ability to perform three specified work tasks with no prospect of improvement. Since medical evidence showed a treatment option (CT guided injection) was available that could potentially improve Mr G's symptoms, L&G was entitled to conclude the disability was not permanent at that time. The ombudsman noted that although Mr G chose not to pursue the recommended treatment due to risk concerns, this did not make L&G's position unfair. The ombudsman also found that L&G's consultation with its Chief Medical Officer demonstrated thorough consideration of the claim.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website