Critical & Serious Illness Decision Reference 2025-0176

• Case Outcome: Rejected
• Year: 2025
• Reference: 2025-0176
• Date: 10 December 2025
• Subject Matter: Critical & Serious Illness
• Finantial Sector: Insurance
• Conducts Complained Of: Rejection of claim - non-medical necessity,Failure to provide correct information

Decision Ref:

2025-0176

Sector:

Insurance

Product / Service:

Critical & Serious Illness

Conduct(s) complained of:

Rejection of claim - non-medical necessity

Failure to provide correct information

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

Background

This complaint relates to a Guaranteed Term Protection Policy (the "Policy") that the

Complainant holds with the Provider and the Provider's decision to decline the

Complainant's claim made on 2 March 2021 (declined on 6 April 2021) and subsequent

appeal in April 2021 (declined on 11 June 2021).

The Policy is owned by the Complainant who is a limited company, and the sole life insured

under the Policy is a director of the company. The Complainant is represented by the

director of the company who is the sole life insured under the Policy and will be referred

to as the Complainant in this Decision.

The Complainant’s Case

The Complainant says that he was diagnosed with prostate cancer in January 2021 and

was advised by his Consultant Urological Surgeon that the cancer was "stage T2 due to

cancer being present in both lobes of the prostate."

- 2 -

/Cont’d…

The Complainant says that he checked the terms of the Policy and that the terms state that

if the cancer is T2 then the Provider will make full payment of a claim.

The Complainant asserts that the Provider contacted him by email on 9 August 2021

informing that it would not be paying the full claim "because [the Provider] claim[s] that,

based on the evidence [it] ha[s] reviewed, there is 'no clinical features to suggest pT2

disease'."

The Complainant asserts that the communication from the Provider in relation to his claim

"has been unprofessional and error prone. [The Provider] ha[s] made numerous errors in

processing this claim. These errors and omissions and incorrect information have caused

[the Complainant] stress and distraction while [he] [is] continuing to run [his] business and

receive [his] cancer treatment." The Complainant submits that "[a]t one stage during a

phone call with [the Provider's] claims agent [he] was told that if [he] proceeded with [his]

chosen course of radiotherapy that [he] would destroy the cancer and any evidence that

[his] cancer was indeed T2."

The Complainant says that the Provider informed him that it would require surgery to

confirm his Consultant Urological Surgeon's opinion that his cancer is classified as T2 and

that "this is stressful for [him] as [he] ha[s] opted for Brachytherapy, rather than surgery,

to treat [his] cancer." The Complainant says that "[t]he histology of the biopsy report

clearly shows that there are cancer tumours on both sides of the prostate but despite this

information [the Provider] ha[s] denied the claim on appeal. [The Complainant] ha[s]

checked and rechecked the TNM definitions for prostate cancer and based on this research

[he] [is] sure that if the cancer is present in both sides that the classification is T2."

The Complainant says that the Provider informed him that when it received confirmation

of his radiotherapy treatment that it would "consider a partial payment serious illness

payment of €15,000 [(fifteen thousand euro)]." The Complainant says that he has asked

the Provider whether, should he accept this, it will preclude him from making a complaint

and seeking the full claim value, to which the Complainant says the Provider has not

answered and as such, the Complainant is unsure whether it will prejudice his claim if he

accepts the lower claim of €15,000.

In terms of how the Complainant wishes for the complaint to be resolved, he says that he

wants the Provider to pay the full claim due under the Policy which amounts to €81,150

(eighty one thousand, one hundred and fifty euro).