Not upheld: claim decline — application of pre-existing condition exclusion complaint against National Deposit Friendly Society Limited

Decision detail

Summary

Mr T claimed on his income protection insurance policy after injuring his back in a slip accident in January 2025. National Friendly initially paid the claim but subsequently declined it, citing the policy's pre-existing condition exclusion. Mr T had undergone an MRI scan and experienced back pain symptoms very shortly before taking out the policy in November 2024. The ombudsman found that the medical evidence supported National Friendly's conclusion that Mr T's inability to work was primarily due to a pre-existing condition made worse by the accident, not a new injury. The ombudsman upheld National Friendly's decision to decline the claim as a fair and reasonable application of the policy terms.

The Ombudsman's reasoning

The ombudsman found that the medical evidence clearly supported that Mr T had signs and symptoms of neck and back pain (including an MRI scan) very shortly before the policy started in November 2024. The policy's pre-existing condition exclusion applies to any disease or injury for which there has been medication, advice, treatment, or signs or symptoms in the 5 years before the policy start date. The ombudsman was satisfied that the primary reason Mr T was unable to work was due to this pre-existing condition made worse by the January 2025 accident, not a new injury caused by the accident. The February 2025 MRI scan was clinically unremarkable and similar to the earlier scan, supporting this conclusion. The ombudsman placed less weight on the November 2025 letter from the orthopaedic surgeon as it did not adequately address the policy definition of pre-existing condition or explain why the pre-existing symptoms were not made worse by the accident.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website