DRN-6250432

The complaint Mrs J’s complained that the Royal London Mutual Insurance Society Limited, trading as Scottish Provident (“SP”) have unfairly declined the claim she made on her critical illness policy. Mrs J has been assisted by her husband in this complaint. Comments and submissions attributed in this decision to Mrs J include those made by Mr J on her behalf. What happened In 2021, Mrs J suffered a traumatic brain injury when she fell down a flight of stairs. This has unfortunately left her with significant ongoing health issues which impact her on a daily basis and she is no longer able to work. So, in early 2025, she made a claim on her SP critical illness policy. The policy doesn’t offer cover for traumatic brain injury. So SP assessed the claim against the policy definition of total permanent disability (TPD), for which Mrs J had cover, dependent whether she could complete the stated Functional Ability Tests. Having done this, they declined the claim. They said Mrs J wasn’t unable to perform any two of the five tests, although they acknowledged she did need to pace herself when she undertook tasks. Mrs J complained, but SP didn’t change their decision. So Mrs J brought her complaint to the Financial Ombudsman Service. Our investigator reviewed the information provided by both parties and concluded SP didn’t need to do anything different to resolve the complaint. He acknowledged her quality of life had been limited since the accident and that her ability to complaint the functional ability tasks varied. But he didn’t think it was reasonable to say she couldn’t perform any of them at all – which was the test set out in the policy. Mrs J didn’t agree with our investigator’s view. So I’ve been asked to make a final 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 Mrs J’s complaint. I know this isn’t the outcome she was hoping for and I’m sorry my decision will disappoint her. I hope it will help if I explain how I reached it. I’ll do so, focusing on the points and evidence I consider material to my decision. So if I don’t mention something in particular, it’s not because I haven’t thought about it. Rather, it doesn’t change the outcome of the complaint. The information I’ve read shows Mrs J has struggled with a variety of symptoms since her accident, including severe migraines and balance issues. It’s very clear to me these have had a significant impact on her life. But I can’t say that SP should pay her claim simply because of this. I can only say they should do something different if I don’t think they’ve considered and applied the terms of her policy fairly and reasonably.

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The policy doesn’t provide cover for brain injuries. So SP considered whether Mrs J met the criteria to claim for TPD. Having reviewed the conditions covered, I think that was reasonable. The policy says TPD can either be assessed on an “own occupation” basis, or on the policyholder’s ability to carry out functional ability tests. Although the medical evidence shows Mrs J is no longer able to perform her former job role, the policy schedule shows her TPD cover is provided functional ability tests basis. So it’s fair for SP to have assessed her claim against those tests. TPD assessed on this basis is defined as: “Becoming permanently disabled before age 65, either: • through illness (other than mental illness of any kind) or injury to the extent of being unable to perform (using any appropriate assistive aids and appliances) any 2 of the 5 Functional Ability Tests listed below,… The disability must be irreversible with no reasonable prospect of there ever being any improvement. The Functional Ability Tests are: • Walking – able to walk 200 metres on the flat without stopping or severe discomfort. • Bending – able to get into or out of a standard saloon car, or able to bend or kneel to pick up a tea cup from the floor and straighten up again. • Communicating – able to answer the phone and take a message. • Reading – having the eyesight required to be able to read a daily newspaper. • Writing – having the physical ability to write legibly using a pen or pencil.” I appreciate from the evidence I’ve seen that Mrs J struggles in all of these areas. Her comments on the investigator’s view say that her ability to carry out activities is “…limited, unpredictable and dependant on strict pacing” and that they can’t be carried out safely, reliably or sustainably. But the policy says that, for a claim to be successful, she must be “unable” to perform at least two of the tasks. I think it’s reasonable to say that means Mrs J can’t perform them at all. All of the evidence provided by her and her doctors points to the difficulties Mrs J encounters in dealing with the tasks - not that she can’t do them at all. In the circumstances, I think SP’s conclusion that she didn’t meet the criteria for a successful TPD claim was reasonable. I don’t mean anything I’ve said in my decision to make light of the difficulties Mrs J faces on a daily basis. I can see they are significant, even though I’m not satisfied they currently meet the policy terms. And, while I sincerely hope she won’t deteriorate further, I’d expect that, if she does, SP would reassess any new evidence relating to her condition to see if the deterioration means that she meets the criteria for a claim to be paid at that time. But, for the time being, I don’t think SP need to do any more to resolve Mrs J’s complaint. My final decision For the reasons I’ve explained, I’m not upholding Mrs J’s complaint about the Royal London Mutual Insurance Society Limited, trading as Scottish Provident. Under the rules of the Financial Ombudsman Service, I’m required to ask Mrs J to accept or reject my decision before 12 May 2026. Helen Stacey

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Ombudsman

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