Legal and General Assurance Society Limited · DRN-6182875

The complaint Mr T’s complained that Legal and General Assurance Society Limited (“L&G”) unfairly declined the claim he made on his critical illness policy after his son was born deaf. What happened Mr T has the benefit of critical illness cover with L&G. The policy also provides cover for children in certain circumstances. In 2024, Mr T’s son (“R”) was born profoundly deaf. So he made a claim to L&G under the policy. L&G assessed R’s medical information and declined the claim. They said he didn’t meet the policy definition of “Deafness – permanent and irreversible” which says: “Permanent and irreversible loss of hearing to the extent that the loss is greater than 95 decibels across all frequencies in the better ear using a pure tone audiogram.” They said R’s hearing loss couldn’t be said to be permanent or irreversible because his auditory Brainstem Response (ABR) results were below the 95 decibel threshold. And the loss couldn’t be said to be irreversible because R was a good candidate for cochlear implants. Mr T complained about L&G’s decision and that there had been delay in reaching it. He said that R was too young to have the tests set out in the policy definition and the tests that were possible on a child of his age confirmed hearing loss. And he said cochlear implants would not reverse his profound deafness. L&G accepted they hadn’t processed the claim to the standard they should have. They paid Mr T £500 compensation for this. But they maintained their decision to decline the claim had been right. Mr T didn’t think this resolved his complaint and brought it to the Financial Ombudsman Service. He confirmed he was satisfied with the compensation he’d received. So our investigator focused her review on the claim decision. Having done that, she concluded L&G didn’t need to do anything different to resolve the complaint as she was satisfied they’d considered and decided the claim in line with the policy terms. Mr T didn’t agree with our investigator’s view. So the matter’s been passed 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. Having done that, I’m not upholding Mr T’s complaint. I know this isn’t the outcome he was hoping for. I hope it will help if I explain the reasons for my decision.

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I can only imagine the impact finding out R is deaf had on Mr T and his family. He’s told us he hoped that a successful claim would help fund the significant adjustments they have to their lives they now have to make. So I understand how difficult it must have been to have the claim declined and the stress that would have added to the family’s situation. But I can only say that L&G should do something different to resolve his complaint if I don’t think they considered his claim fairly and reasonably. To make that decision I have to look at the policy terms. I’ve set out the policy definition of deafness in the section above. Mr T told L&G that R is too young to have the tests set out in the policy term, and it was unfair to apply them to this claim. L&G accepted that was the case and agreed to disregard that part of the definition and consider only whether the hearing loss was permanent and irreversible. I think that was fair. The policy sets out specific definitions of both “permanent” and “irreversible”. “Permanent” is defined as: “…expected to last throughout the insured person’s life, irrespective of when the cover ends or the insured person retires”. There doesn’t appear to be any dispute that R’s deafness will sadly be permanent. But it also has to be irreversible. That’s defined as: “…cannot be reasonably improved upon by medical treatment and/or surgical procedures used by the National Health Service in the UK at the time of the claim”. L&G say the fact that R is a candidate for cochlear implants means this part of the term hasn’t been met. Mr T has said that cochlear implants don’t reverse deafness – rather, they operate as a receiver for signals which mimic natural sound. I don’t doubt what he says. But the policy has set out a specific meaning for “irreversible” which doesn’t require deafness to be reversed. To be irreversible for the purposes of the policy, there must be nothing which can reasonably improve the situation for R. As I understand it, he can hear nothing without implants. So I can’t reasonably say that even the mimicking of natural sound Mr T describes isn’t an improvement. That, unfortunately for Mr T’s claim, means the policy definition hasn’t been met. And I can’t say L&G’s decision to decline the claim was unfair or unreasonable. L&G have said that, if implants aren’t successful, the claim can be reconsidered in light of that evidence. That’s what I’d expect them to do. But, for the time being, I don’t think they need to do any more to resolve Mr T’s complaint. My final decision For the reasons I’ve explained, I’m not upholding Mr T’s complaint about Legal and General Assurance Society Limited. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr T to accept or reject my decision before 2 April 2026. Helen Stacey Ombudsman

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