Legal and General Assurance Society Limited · DRN-6033733

The complaint Miss H is unhappy with the service she received from Legal and General Assurance Society Limited when it declined her claim. What happened Miss H has critical illness cover with L&G through her employer. She made a claim for deafness as she lost the ability to hear in her left ear. Miss H said L&G should have told her from the outset that her claim wasn’t payable because she still retained hearing in her right ear. Miss H also said L&G misled her into thinking her claim was payable because its communications were unclear. She’d like compensation for the distress caused by her unduly raised expectations. L&G said it declined her claim because the Miss H hadn’t lost her hearing in both ears. It said after checking she was eligible to claim, it then completed its investigation by considering the available medical evidence to determine liability. It apologised for the confusion caused, particularly as Miss H was under the impression her claim had been accepted after L&G confirmed eligibility. Our investigator didn’t uphold this complaint. She said the apology from L&G was a fair acknowledgement of the confusion caused. She explained L&G needed to assess the medical evidence before deciding liability, so it couldn’t have given her an answer without following that process. Miss H, unhappy with that, asked for an ombudsman to consider her complaint. In summary, she said when L&G told her she’d passed the eligibility checks, she wasn’t told what that meant. She maintained it was reasonable for her to assume it meant her claim was covered. Miss H said the overall service she received was poor and that L&G should pay her compensation. So the complaint has been passed to me to decide. 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. Having done so, I’ve decided not to uphold it and for broadly similar reasons to those given by our investigator. I don’t think L&G could have reasonably given Miss H an answer to the claim at the point she raised it. I accept Miss H was unaware the policy’s definition of hearing loss meant it needed to be in both ears, but I still don’t think L&G could have given her an answer any sooner. I’ll explain why. The relevant rule that applies in this case comes from the Insurance Conduct of Business Sourcebook (ICOBS) and says L&G must assess claims promptly and fairly and must not reject a claim unreasonably. I’ve considered this and other relevant industry guidance whilst assessing Miss H’s complaint. Although I may not respond to every point Miss H has raised, I want to reassure her I’ve

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considered everything she’s said. The informal nature of this service enables me to do that so I can resolve complaints with minimal formality. Miss H accepts her claim isn’t payable and so I’ve decided not to revisit L&G’s decision as part of my final decision. Her issue is that L&G ought to have told her, at the beginning of the claims journey, the deafness benefit only pays out if she loses her hearing in both ears. I understand the argument she’s making and whilst I think L&G could have been clearer on that point from the outset, I don’t think it could have reasonably given an answer to her claim without assessing the medical evidence first. Under ICOBS L&G must handle claims fairly. That means I’d expect it to assess the available medical evidence before making a decision about liability for her claim. So, whilst it could have given Miss H an earlier steer, in the way she’s outlined, it still wouldn’t have been able to provide an answer on the outcome of her claim, until it’d reviewed her medical evidence. Miss H said she found L&G’s messaging around her claim’s eligibility misleading. This is because once she’d submitted her claim, L&G had to check whether it met the eligibility criteria. This typically involves checking things like the consumer’s eligibility to bring a claim under their employer’s policy and the level of benefit available. The email sent to Miss H, whilst didn’t explain that in any particular detail, said her claim form and the medical evidence would be reviewed separately. L&G accepted it could have been clearer and apologised for the confusion caused, which I thought was reasonable. I’ve thought carefully about Miss M’s argument for compensation but I’m persuaded L&G’s apology is fair and reasonable in the circumstances. I note Miss H said she didn’t have a copy of the policy terms prior to making her claim. She explained had she been provided a copy, she wouldn’t have submitted her claim as she’d have been clear about the policy’s requirement for deafness benefit. I see why she makes that argument but that’s not L&G’s responsibility to provide her with that information. Her employer is the policy holder and therefore the party responsible for doing that. My final decision For the reasons I’ve explained, I don’t uphold this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Miss H to accept or reject my decision before 24 April 2026. Scott Slade Ombudsman

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