Royal London Mutual Insurance Society, Limited · DRN-6103696

The complaint Mr G and Miss L complain that Royal London Mutual Insurance Society, Limited (THE) trading as Royal London, declined a claim they made on a life and critical illness policy. What happened Mr G and Miss L held a joint life and critical illness insurance policy. Mr G claimed on the policy following a diagnosis of vestibular schwannoma (a tumour which develops in the ear). Royal London declined the claim as they said Mr G hadn’t accurately declared his medical history and, had he done so, they wouldn’t have offered cover. Mr G and Miss L complained to Royal London but they maintained their decision was fair. They said Mr G ought to have updated them when he was referred to a specialist and had been experiencing symptoms before the policy was taken out. Unhappy, Mr G and Miss L referred their complaint to the Financial Ombudsman Service. Our investigator looked into what happened and didn’t uphold the complaint. She thought Royal London had reasonably declined the claim. Mr G and Miss L didn’t agree and asked an ombudsman to review the complaint. In summary, Mr G says that he didn’t receive written confirmation of the referral and that the symptoms he was experiencing were intermittent and minor. He also said Miss L no longer had cover as the policy had been voided in it’s entirety. So, the complaint was referred to me to make a 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. I’m sorry to read of the circumstances which led to Mr G making a claim. I have a lot of empathy for the circumstances he’s described. I understand he’s recently undergone treatment and I hope that his recovery is going as well as possible. The relevant rules and industry guidelines say that Royal London have a responsibility to handle claims promptly and fairly. And they shouldn’t reject a claim unreasonably. The relevant law in this case is The Consumer Insurance (Disclosure and Representations) Act 2012 (CIDRA). This requires consumers to take reasonable care not to make a misrepresentation when taking out a consumer insurance contract (a policy). The standard of care is that of a reasonable consumer. And if a consumer fails to do this, the insurer has certain remedies provided the misrepresentation is - what CIDRA describes as - a qualifying misrepresentation. For it to be a qualifying misrepresentation the insurer has to show it would have offered the policy on different terms or not at all if the consumer hadn’t made the misrepresentation. CIDRA sets out a number of considerations for deciding whether the consumer failed to take reasonable care. And the remedy available to the insurer under CIDRA depends on whether

-- 1 of 3 --

the qualifying misrepresentation was deliberate or reckless, or careless. Royal London says Mr G failed to take reasonable care during the application process in December 2023 when he was asked questions about his medical history. They’ve also said that he failed to update them when he was referred to a specialist between the application and the policy start date. So, I’ve looked at the questions Mr G was asked and the information he was provided with. “APART FROM ANYTHING YOUVE ALREADY TOLD US ABOUT, DURING THE LAST 5 YEARS HAVE YOU HAD, OR DO YOU CURRENTLY HAVE, ANY OF THE FOLLOWING: Any condition affecting your ears or hearing, or your eyes or vision that is not wholly corrected by spectacles or lenses? Including: Blindness or impaired vision, Deafness or impaired hearing, Blurred or double vision, Tinnitus, Menieres disease, Labyrinthitis, Glaucoma. APART FROM ANYTHING YOU HAVE ALREADY TOLD US ABOUT, IN THE LAST 3 YEARS, HAVE YOU: Been prescribed medication or treatment regularly for a period of four consecutive weeks or more, or have you been under review from your doctor or a medical professional? Including Physio, counselling, Prescriptions from your own doctor, even if you did not take them. You don't need to tell us about contraception, fertility, dental treatment or reviews purely in relation to pregnancy. Mr G answered ‘no’ to both. However, Mr G’s medical history demonstrates that in November 2023 Mr G visited his GP for right ear pain and constant ringing. He was prescribed medication. Furthermore in December 2023, shortly before the application, he visited his GP with a history of his ear ringing with a high pitched sound. I think Mr G ought to have disclosed the GP visits to Royal London. Even if Mr G didn’t think the condition was tinnitus he’d attended a GP, been prescribed medication and had a condition impacting his ears and/or hearing. The list set out in the question isn’t exhaustive and I think it ought reasonably to have prompted Mr G to disclose his symptoms, particularly as he’d visited the GP so recently. Furthermore, Mr G was asked: “APART FROM ANYTHING YOU HAVE ALREADY TOLD US ABOUT, IN THE LAST 3 YEARS, HAVE YOU: Been referred to a specialist or had, or been advised to have, any investigations? Including: Blood tests, Biopsy, Ultrasound, X-Ray, CT / MRI or other scan, ECG, echocardiogram or other heart investigation, Abnormal smear or abnormal mammogram, Investigations using an internal camera such as an endoscopy, colonoscopy or laparoscopy You don't need to tell us about investigations which were purely for pregnancy, infertility or simple fractures which have resolved with no time off work, or about genetic tests that meet the criteria outlined previously.” Between applying the policy and the inception date Mr G was referred to a specialist. Ultimately this led to the diagnosis of the tumour. I appreciate that Mr G says he didn’t

-- 2 of 3 --

receive a letter about the referral. However, Mr G’s own testimony was that: ‘my later appointment with a GP in July 2024, to chase things up, shows that by that later stage I had become concerned that nothing had come through – it does not prove that, between 6 and 18 March 2024, I knew a formal referral had already been processed or that there was any concrete development to report to Royal London”. He also said in previous correspondence that he attended his new GP in July 2024 ‘because I was concerned no referral confirmation had come through’. The policy documentation reminded Mr G to let Royal London know of any changes to the answer to the questions. His GP notes indicate that the referral was made on or around 6 March 2024 as the symptoms were worsening. Even if Mr G didn’t receive a letter his own testimony indicates in my view that, on the balance of probabilities, it had taken place or further investigations into his symptoms were planned. So, I think Royal London fairly concluded he ought to have let them know about this development. In reaching this conclusion I’ve considered that Mr G did disclose other medical conditions during the application process. However, it was his responsibility to ensure that Royal London had all of the relevant medical information. Royal London has provided underwriting evidence demonstrating that if Mr G had let them know about the referral or investigations the policy wouldn’t have incepted. Instead, Royal London would have waited for the outcome of the investigations and referral. Ultimately, the policy wouldn’t have been offered as it would have been postponed pending the outcome of the referral. This means I’m satisfied Mr G’s misrepresentation was a qualifying one. Royal London has treated the misrepresentation as careless. I think that’s fair as I don’t think Mr G sought to deliberately mislead Royal London. I’m satisfied that it’s most likely he didn’t fully appreciate the significance of this information to Royal London. As I’m satisfied that Mr G’s misrepresentation should be treated as careless I’ve looked at the actions Royal London can take in accordance with CIDRA. In such circumstances they are entitled to decline the claim, cancel the policy and refund the premiums. That’s what they’ve agreed to do. I think that’s in line with CIDRA and fair and reasonable in the circumstances. Mr G feels it isn’t proportionate for the whole policy to be cancelled as Miss L is covered too. I’ve taken into account good industry practice including the relevant Code for insurers issued by the Association of British Insurers. Even though the policy is a joint one, I’m satisfied it is fair and reasonable for Royal London to apply the principles of CIDRA to the whole policy as this policy wouldn’t have been offered at all. So I think Royal London’s actions in cancelling the whole policy are fair and reasonable in the circumstances of this case. My final decision I’m not upholding this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr G and Miss L to accept or reject my decision before 20 April 2026. Anna Wilshaw Ombudsman

-- 3 of 3 --