Critical & Serious Illness Decision Reference 2021-0369

• Case Outcome: Partially upheld
• Reference: 2021-0369
• Date: 13 October 2021
• Year: 2021
• Subject Matter: Critical & Serious Illness
• Conducts Complained Of: Rejection of claim
• Finantial Sector: Insurance

Decision Ref:

2021-0369

Sector:

Insurance

Product / Service:

Critical & Serious Illness

Conduct(s) complained of:

Rejection of claim

Outcome:

Partially upheld

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

Since 2001, the Complainant has held an insurance policy with the Provider called a ‘Serious

Illness Plan’ referred to in this Decision as “Policy C”. Her husband is listed as the life

assured. The complaint concerns a declined serious illness claim.

The Complainant’s Case

The Complainant, now age 79, says she has held a number of policies with the Provider since

the early 1980s.

In particular, the Complainant says that in 2001 she incepted a ‘Serious Illness Plan’ with the

Provider, with her husband listed as the life assured.

Following her husband undergoing open heart surgery in January 2019, the Complainant

sought to claim a serious illness benefit under her ‘Serious Illness Plan’ but she says that the

Provider rejected the claim and advised that the policy did not include serious illness cover.

In her undated letter to this Office received on 4 June 2019, the Complainant submits:

“ … This Policy was sold to us initially as a Serious Illness Policy, and has always been

referred to by [the Provider] in all [its] correspondence to us down through the years

as such … Obviously this has been very misleading for us, as we have always

understood it to be a Serious Illness Plan …”