Legal and General Assurance Society Limited · DRN-6113868

The complaint Ms M is unhappy with Legal and General Assurance Society Limited’s decision to decline her claim, unwind her policy and return the premiums she paid. (Ms M brings her complaint through a third-party representative. For simplicity, I’ll refer to all submissions as being made by Ms M personally). What happened Ms M sourced a critical illness policy through her financial adviser in July 2018. Ms M was diagnosed with multiple sclerosis (MS) in December 2023 and made a claim under the policy she held with L&G. Her claim was declined because L&G noted she’d not shared relevant information about her past medical history when asked at the application stage. Ms M said she didn’t misrepresent her medical history, rather, her symptoms of vision and hearing problems had fully resolved by the time she applied for the policy. Ms M said had she continued to suffer with those issues, then she’d have declared that to the insurer. L&G said Ms M failed to take reasonable care when answering the health screening questions. It said had it known the full extent of Ms M’s medical history and there was no official cause identified for her previous hearing loss, it would have postponed offering a policy. It said as the policy wouldn’t have been in place there’s no cover to consider the claim against. L&G paid Ms M £300 compensation for delays caused whilst assessing her claim. Our investigator didn’t uphold this complaint. She said whilst Ms M wasn’t suffering with symptoms at the time she applied for cover, she was persuaded Ms M should have answered them differently. Our investigator said this was a careless misrepresentation, as well as a qualifying one, and said L&G had reasonably declined the claim and returned the premiums. Ms M, unhappy with that, asked for an ombudsman to review her complaint. In summary, she said there was nothing for her to disclose given her symptoms of hearing loss, double vision and balance problems had resolved by the time she applied for cover. She also said her symptoms were caused by a viral infection which L&G said she didn’t need to tell it about. Ms M said L&G’s decision to retrospectively apply the medical evidence to withdraw her cover is unfair and she noted the underwriters were also unsure whether a misrepresentation had occurred and how to categorise it – which she believes is evidence that supports the complexity of her case. And so, it’s now for me to make a final decision. What I’ve decided – and why I’ve considered all the available evidence and arguments to decide what’s fair and reasonable in the circumstances of this complaint.

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Having done so, I’ve decided not to uphold it and for broadly similar reasons as our investigator. I’m persuaded the health and lifestyle questions asked by L&G at the application stage were clear and that Ms M should have answered them differently. The evidence provided by L&G shows it wouldn’t have offered Ms M a critical illness policy at that time had she answered the questions accurately and so it can reasonably unwind the policy from inception and decline the claim. I’ll explain why. The relevant law that applies in this case is the Consumer Insurance Disclosure and Representations Act 2012 (CIDRA). This law sets out the actions available to the insurer should a misrepresentation occur. I’ve considered L&G’s actions to ensure they’re consistent with the available remedy under CIDRA. L&G said this is a qualifying misrepresentation, which means it would have done something differently had it known the full extent of Ms M’s medical history. The questions L&G asked were: “Health – Ever • Have you ever: had any neurological condition or visual disturbance, for example epilepsy, multiple sclerosis, muscular dystrophy, cerebral palsy, motor neurone disease, Parkinson's disease, optic neuritis? Please ignore long and short sightedness that's been corrected” and: “Health - Last 5 years continued. When answering the following questions, if you're unsure whether to tell us about a medical condition, please tell us anyway. Apart from anything you've already told us about in this application, during the last 5 years have you seen a doctor, nurse or other health professional for: • any condition affecting your ears or hearing, for example Meniere's disease, deafness? Please ignore simple earache and ear infections that have resolved leaving no continuing hearing loss. • any condition affecting your eyes or vision, not wholly corrected by spectacles, lenses or laser treatment, for example cataract, blindness? • paralysis, numbness, persistent tingling or pins and needles, tremor or facial pain other than dental pain? Memory loss, dizziness or balance problems?” Ms M answered no to these questions when L&G said she should have answered yes. Having carefully considered the arguments provided by both the insurer and Ms M, I’m satisfied she should have answered differently and disclosed her issues with hearing loss, visual disturbance and dizziness. I say that because the evidence shows Ms M suffered with these symptoms in April, May and June in 2017 and so should have been disclosed when she took the policy a year later in July 2018. The evidence shows Ms M consulted her GP for her symptoms of sudden onset of hearing loss in April 2017 and was referred to an ENT specialist. In May 2017 the specialist noted Ms M’s symptoms of sudden hearing loss, double vision and dizziness, the cause was unknown. Ms M was prescribed medication and asked to return in six weeks for a follow up. That happened in June 2017 where it was noted Ms M’s symptoms had improved but not fully resolved.

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Ms M said she didn’t disclose this to L&G because her financial adviser said it wasn’t necessary. I should say I’m not considering a complaint about the adviser and so I make no finding on that point. Ms M also said her symptoms had resolved following the medication she was prescribed in May 2017, but that’s not supported by the medical evidence as her follow up appointment in June, although shows an improvement, there were still symptoms present. L&G highlighted later medical evidence in 2021 and 2023 where Ms M seemingly confirmed her symptoms from 2017 had never fully resolved, which is consistent with the contemporaneous medical evidence. A letter from Ms M’s consultant neurologist in November 2023 noted she was still suffering with symptoms of double vision and her balance never recovered. So, I’m satisfied this was information she ought to have shared with the insurer back in 2018 when she took the cover as the evidence shows Ms M’s symptoms were unresolved at that point in time and continued to be persist even after the policy was incepted. Ms M made other arguments about the cause of her symptoms being related to a viral infection, but that’s not supported by the medical evidence either. The ENT specialist said the cause was unknown and that there was no viral or upper respiratory tract infection at that time. So I remain persuaded Ms M should have answered the relevant questions differently in the circumstances. L&G said had it known about these issues, it would have wanted to review Ms M’s medical records and discuss her symptoms further. The insurer said it wouldn’t have offered her a policy at the time and so I’ve carefully considered its reasons for that. I’ve reviewed L&G’s underwriting criteria, overlaying Ms M’s medical history to decide whether L&G has treated her fairly by refusing cover. Due to the commercially sensitive nature of this evidence, I’m unable to share it with Ms M, but I wanted to reassure her I’ve given it due consideration. The evidence shows L&G would not have offered her critical illness cover in July 2018, so I’m satisfied the action taken by the insurer to cancel the policy is fair. It therefore follows I find L&G reasonably declined Ms M’s claim as there was no policy to consider it against. When L&G realised there was the possibility of a misrepresentation having occurred, it went about gathering the necessary medical evidence to determine exactly what had happened. Ms M pointed to some of the insurer’s claims notes where it was trying to establish whether the misrepresentation was careless or deliberate and said that shows her case is boarder line and complex. I understand the argument she’s making but I’m not persuaded that’s the case here. I should say the evidence highlighted by Ms M simply shows the insurer’s considerations about the misrepresentation at different times throughout its investigation. This isn’t unusual and the categorisation is subject to change depending on the evidence received as part of any investigation. At one point L&G thought the misrepresentation was deliberate, but it ultimately decided it was careless after reviewing the answers Ms M provided. For the avoidance of any doubt, I also think it was a careless misrepresentation. CIDRA says the insurer must return the premiums where a careless misrepresentation has occurred, which I’m aware L&G has already done and so there’s nothing more it needs to do in the circumstances. My final decision For the reasons I’ve explained, I don’t uphold this complaint.

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Under the rules of the Financial Ombudsman Service, I’m required to ask Ms M to accept or reject my decision before 27 April 2026. Scott Slade Ombudsman

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