Royal London Mutual Insurance Society Limited · DRN-6260155

The complaint Mr and Mrs H complain that Royal London Mutual Insurance Society Limited (‘Royal London’) unreasonably refused a claim Mr H made for terminal illness benefit under their joint life assurance policy. What happened Mr and Mrs H are now represented by their two sons (who I’ll call Mr N and Mr O for ease of reading) in bringing this complaint. Mr and Mrs H took out a Bright Grey Personal Protection Menu policy in September 2012 for a 15-year term. It offers both a level and decreasing sum assured along with an additional monthly income payment in the event that either of them were to pass away or be diagnosed with a terminal illness during the policy term. On 5 November 2025, Mr H was informed by his treating clinical oncology consultant, Dr B, that his earlier diagnosis of a type of cancer was sadly incurable, since previous treatment therapies had been unsuccessful. At that time, he was also given a special rules (‘SR’) for end of life medical report form. He made a claim to Royal London for terminal illness benefit the same day. On 12 December 2025, Royal London rejected the claim. It said that after seeking a medical report from Dr B, its chief medical officer (‘CMO’) couldn’t conclude that the policy definition had been met at that time. That was since the medical evidence did not show evidence of disease progression. And it noted Mr H was due to undergo palliative immunotherapy and possible third-line chemotherapy. Mr and Mrs H complained. They said that they believed the information from Dr B was sufficient to meet the wording in their policy, and Royal London was unfairly delaying a claim at a time when Mr H had an extremely limited life expectancy. On 5 January 2026, Royal London rejected the complaint. It accepted that Mr H sadly had an incurable condition. However, it felt that the availability of potential treatments open to him meant that it wasn’t possible to accurately predict whether Mr H had a life expectancy of less than 12 months. It also noted that the SR form was completed by a nurse, not a treating consultant. Mr and Mrs H lodged the complaint to this service. They supplied evidence of the proposed immunotherapy which showed patients had a median prognosis of 7.5 months. Mr and Mrs H believed that Royal London was wasting their limited time by delaying matters unduly and disputing the view of a qualified medical professional. In February 2026, Mrs H explained that Royal London had now agreed to pay the claim. She and Mr H had supplied further explicit information from Dr B about his life expectancy in light of the palliative treatment options, which was assessed by Royal London on 23 January 2026. Mrs H explained that she had also raised a second complaint to Royal London in respect of its poor customer service.

-- 1 of 4 --

The complaint was reviewed by one of our investigators, but she didn’t think it ought to succeed. She said that the medical information Royal London received from Dr B didn’t provide confirmation that Mr H was likely to pass away within 12 months, but that was what the policy terms required in order to pay a valid claim. Mr N told our investigator that Mr and Mrs H didn’t accept her view on the complaint. They said that the SR form was reasonable evidence, as it is a government-mandated form used where a person has less than 12 months to live. Furthermore, Dr B had emailed Royal London on 16 December 2025 confirming she believed Mr H met the policy definition. Mr N said that if Royal London could now accept the claim, it must have unduly dragged its heels as it was relying on effectively the same medical evidence that it had received from the outset. Mr N finally explained that mishandling of the claim has severely affected Mr H’s ability to enjoy the remainder of his very limited period of life expectancy. Our investigator wasn’t minded to change her view on the complaint, so Mr N asked for it to be passed to an ombudsman. He explained that he felt Royal London had unfairly relied on the approval of its CMO. And if it knew that all it would take for the claim to be agreed was confirmation of the life expectancy of less than 12 months from Dr B, he questioned why it didn’t merely ask her for that directly. Mr N noted that where there was a difference between an insurer’s internal medical opinion and that of the treating consultant, he would expect the insurer to seek clarification from the consultant before declining the claim. This was particularly important in a terminal illness claim where time is critical. Mr N contended that Royal London delayed matters by failing to be proactive in going back to Dr B for the precise evidence it required and he felt compensation ought to be awarded for it causing Mr H unnecessary delay and distress. Royal London didn’t have any further comments to make. The complaint has now been passed to me. 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 was sorry to learn of Mr H’s diagnosis, and I send my best wishes to Mr and Mrs H and their sons at what I realise has been, and continues to be, an incredibly difficult time for them. Unfortunately, I am also of the view that this complaint should not succeed.That means I won’t be asking Royal London to do anything further to resolve the complaint. In reaching my findings, I’ve set out the background to this complaint in less detail than the parties and I’ve done so using my own words. I’ve also focused on what I believe to be the central issues in the complaint. If there’s something I haven’t mentioned, it isn’t because I’ve ignored it - rather, it’s because I don’t need to comment on every argument in order to reach what I believe is the right outcome in the circumstances. Our rules allow me to take this approach; it reflects the informal nature of our service, as a free alternative to the courts. Before I go any further, it’s also important that I set out the parameters of this decision. I will only be considering the evidence which was available to Royal London up to the point it issued its final response to Mr and Mrs H’s complaint on 5 January 2026, endorsing its decision to refuse their claim for terminal illness benefit. My reasons for not upholding this complaint are:

-- 2 of 4 --

• I can see that Mr N has now confirmed Mr and Mrs H accept that the evidence supplied to Royal London prior to 5 January 2026 was insufficient to satisfy the full policy wording – though this wasn’t their original position when first complaining to Royal London. • So for completeness, I have looked at the claim refusal as that was the crux of the complaint brought to this service. Relevant regulatory rules require Royal London to handle claims promptly and fairly and to not unreasonably reject a claim. • The wording for Mr and Mrs H’s policy says Royal London will pay a claim if a person meets the definition of terminal illness during the term of the policy, which is: “A definite diagnosis by the attending consultant of an illness that satisfies both of the following: o the illness either has no known cure or has progressed to the point where it cannot be cured; and o in the opinion of the attending consultant, the illness is expected to lead to death within 12 months.” • Up to the date of the complaint outcome (incorporating Mr and Mrs H’s appeal to the decision) on 5 January 2026, Royal London says it did not receive confirmation to satisfy the second point of the policy wording above. And I agree with this contention. • Though I appreciate the particularly emotive and urgent circumstances of Mr H’s claim, the onus is on a policyholder to provide evidence sufficient to satisfy the policy wording for a valid claim, rather than the insurer. • Dr B’s email of 16 December 2025 didn’t give an express view on Mr H having a life expectancy of less than 12 months, such that both limbs of the policy wording were satisfied. She did explain how Royal London had misunderstood Mr H’s PET scan readings and she referenced a trial with overall median survival rates of 7.5 months for the proposed palliative treatment but she didn’t specifically confirm Mr H’s prognosis. It was for this reason that Royal London’s CMO gave its view on Mr H’s prognosis against the evidence it had seen regarding palliative treatment . • And though Mr H had been able to provide the SR form as further evidence, this didn’t satisfy the policy wording either, since it didn’t give an express opinion from Dr B, nor did it set out his life expectancy. I appreciate that the form is viewed for the purposes of government benefits as setting a threshold of less than 12 months to live but that does differ from what the policy wording required. • I haven’t seen any suggestion that the way Royal London processed the claim was unfair or intended to unduly delay matters for Mr and Mrs H. At the point it receives evidence sufficient to satisfy the claim, the subsequent claim payment should be backdated to that date. And I understand the claim was backdated to the date of Dr B’s email of 23 January 2026 – albeit that falls outside the scope of this complaint. • In any event, following the complaint outcome, I can see that Royal London did reiterate what it required to Mr and Mrs H in a telephone call the week after the final response letter was issued. In an email following the call, a claims handler said: “Thank you for your call earlier and providing the information. I am very sorry that this process is causing you upset at what I know is a difficult time for you and your family. We have looked at all the evidence provided to date, and as explained, it doesn’t meet the Terminal Illness definition at the moment. Just

-- 3 of 4 --

for your reference I have attached the plan details (T&C’s) and I would refer you to B1.2 on page 11 and the definition on page 48. This is a very difficult situation as I know it is hard for a consultant to be specific with life expectancy with a terminal illness but if [Dr B] can confirm her medical opinion is that it would unfortunately, be less than 12 months [Royal London] will be happy to look at [the claim] again as a matter of priority.” • My role is not to substitute my view for that of a business but instead, to determine if a business has behaved reasonably when processing a claim. And overall, I haven’t seen any objective evidence that Royal London acted unfairly in declining the claim up to the appeal outcome on 5 January 2026 or that it unduly delayed matters in that period by failing to inform Mr and Mrs H what was required for a valid terminal illness benefit claim payment. It follows that despite my sympathy for these circumstances, I cannot agree that any compensation is due from Royal London to Mr and Mrs H, as suggested. My final decision I am very sorry to write to Mr and Mrs H with an outcome that I know will be a disappointment for them at an already distressing time. But, I have to be fair to both parties in a complaint. For the reasons given, I cannot uphold this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr and Mrs H to accept or reject my decision before 28 April 2026. Jo Storey Ombudsman

-- 4 of 4 --