Not upheld: claim denial — failure to meet contractual definition of critical illness complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Mr and Mrs B complained that L&G unfairly turned down Mrs B's critical illness claim following her diagnosis with arrhythmogenic right ventricular cardiomyopathy (ARVC) in October 2025. L&G denied the claim because the available medical evidence did not demonstrate that Mrs B's condition met the policy's severity-based definition requiring NYHA Class 3 functional impairment. Although Mrs B's consultant cardiologist Dr N disagreed with L&G's decision and later noted Mrs B had experienced palpitations and exercise limitations, Dr N was unable to assign an NYHA Class 3 grade, and L&G's two independent Chief Medical Officers reached the same conclusion. The ombudsman found L&G acted fairly in relying on the consistent expert medical evidence showing the required severity threshold had not been met, and therefore did not uphold the complaint.

The Ombudsman's reasoning

The ombudsman carefully weighed the expert medical evidence from three independent cardiologists. While acknowledging Dr N's strong disagreement with L&G's decision and Mrs B's symptoms, the ombudsman found that the policy definition clearly requires NYHA Class 3 classification. Critically, all three cardiologists (Dr N and two CMOs) were unable to classify Mrs B's condition as meeting NYHA Class 3 requirements. The ombudsman concluded that L&G fairly relied on this consistent expert evidence to determine that the required severity level had not been met, and therefore L&G did not act unfairly in turning down the claim.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website