Whole-of-Life Decision Reference 2022-0231

• Case Outcome: Partially upheld
• Reference: 2022-0231
• Date: 15 July 2022
• Year: 2022
• Subject Matter: Whole-of-Life
• Finantial Sector: Insurance
• Conducts Complained Of: Poor wording/ambiguity of policy,Failure to advise on key product/service features, Mis-selling (insurance), Rejection of claim

Decision Ref:

2022-0231

Sector:

Insurance

Product / Service:

Whole-of-Life

Conduct(s) complained of:

Poor wording/ambiguity of policy

Failure to advise on key product/service features

Rejection of claim

Mis-selling (insurance)

Outcome:

Partially upheld

LEGALLY BINDING DECISION

OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

The First Complainant and his wife, the Second Complainant, incepted a Protection Portfolio

Policy with the Provider on 23 January 1998. The Complainants have been advised that this

Office cannot examine any element of their complaint relating to the sale of the policy in

September 1997, as the conduct giving rise to that element of the complaint, falls outside

the time limits set out in Section 51 of the Financial Services and Pensions Ombudsman Act

2017.

The complaint concerns the Provider’s decision, more recently, to decline serious illness

indemnity in respect of the First Complainant’s [type redacted] surgery and also the Second

Complainant’s [type redacted] surgery.

The Complainants’ Case

The First Complainant contacted the Provider in December 2016 to query whether his [type

redacted] surgery was covered by the Complainants’ Protection Portfolio Policy. The

Provider advised that this particular surgery was not covered by the serious illness policy

benefit and that in order for cover to apply, the Complainants would have had to have

selected the “living cover benefit” when applying for the policy, which they had not.

Subsequently, after the Second Complainant underwent [type redacted] surgery, the First

Complainant contacted the Provider in June 2017 to complaint that neither his [type

redacted] surgery nor the Second Complainant’s [type redacted] was covered by their policy.