Not upheld: claim denial based on policy exclusion; claims handling error complaint against Royal London Mutual Insurance Society, Limited

Decision detail

Summary

Mr G claimed income protection benefit after suffering a sacral fracture in February 2025. His policy contained a spinal exclusion due to a previous back condition. Royal London initially wrongly indicated it would pay three months of ex-gratia benefit, then corrected this and denied the claim based on the spinal exclusion. Mr G disputed that the sacrum forms part of the spine and argued the exclusion should only apply if his current incapacity was caused by his previous spinal condition. The ombudsman upheld Royal London's decision, finding the spinal exclusion is clear and applies to any spinal injury regardless of cause, that the sacrum is medically established as part of the spine, and that medical evidence clearly linked Mr G's incapacity to the sacral fracture. The £300 compensation already paid for the claims handling error was deemed fair.

The Ombudsman's reasoning

The ombudsman found that the spinal exclusion clause is clear and unambiguous, applying to any incapacity resulting from any disease, disorder or injury to the spine and related structures, regardless of the cause. The sacrum is medically established as part of the spine. Mr G's medical evidence clearly shows his incapacity was caused by the sacral fracture. Therefore, the exclusion applies regardless of whether the injury was accidental or related to his previous spinal condition. The exclusion does not require a causative link to a pre-existing condition; it simply excludes all spinal-related incapacity claims. Royal London reasonably relied on available medical evidence and was not obligated to arrange an independent medical examination.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website