DRN-6252949

The complaint Mrs F’s complained – in her capacity as executor of her late husband’s estate – that Legal and General Assurance Society Limited (“L&G”) unfairly declined the estate’s claim on Mr F’s life insurance policy and voided the policy because they said he’d made a misrepresentation in his application. What happened In summer 2020, Mr F applied to L&G for a life insurance policy. As part of the application, he answered a number of questions about his health and lifestyle, including: “How often do you drink alcohol? During a typical week, how many alcoholic drinks do you have?” Mr F answered “weekly” to the first question. And “4” to the second. Mr F passed away in May 2025. So Mrs F made a claim. L&G obtained Mr F’s medical records to help them assess the claim. Having reviewed these, they declined the claim. They noted that, just a couple of months after he’d applied for the policy, Mr F underwent some gastrointestinal investigations, during which he was noted to be drinking about 4-5 pints per day and had a fatty liver. He was subsequently diagnosed with cirrhosis in late 2021, which was ultimately the cause of his death. L&G concluded from the medical records that Mr F must have answered the application question about his alcohol consumption inaccurately. They said it wasn’t possible for his liver to be as damaged as it was if he was only drinking the amount he’d said in his application. And, if they’d known how much he was drinking at that time, they wouldn’t have offered him a policy. So they declined the claim, cancelled the policy and refunded the premiums Mr F had paid to his estate. Mrs F complained about L&G’s decision. She said that Mr F had worked in a job role which required him to undergo random drug and alcohol tests. So, while she said he might have consumed more alcohol after he bought the policy, he didn’t have the history of heavy drinking L&G had assumed from the records. And she said there were other factors, such as an excess iron in his blood, which could have led to his liver issues. She also complained about the time it had taken L&G to reach their claim decision, mistakes in the letter setting the decision out, and that an automated response to a subject access request had been addressed to Mr F. L&G accepted they’d delayed in letting Mrs F know their claim decision, that the letter setting out that decision contained typing errors and that addressing an email to Mr F had been insensitive. They paid Mrs F £250 compensation for this. But they maintained that their decision to decline the claim was correct as Mr F’s medical records showed a history of heavy drinking.

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Mrs F didn’t think L&G’s response had resolved the estate’s complaint and brought it to our service. Our investigator reviewed the information provided by both parties and concluded L&G’s decision to decline the claim was fair, reasonable and had been dealt with in accordance with the Consumer Information (Disclosure and Representations) Act 2012 (“CIDRA”). Mrs F said the estate didn’t agree with the 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 the estate’s complaint. I know Mrs F will be very disappointed by my decision and I’m sorry about that. I hope it will help if I explain why I’ve made it. I’ve focused on L&G’s decision to decline the claim, as I understand that is the crux of Mrs F’s concerns. I note, while she has received a total of £500 compensation from L&G for the shortcomings they identified when they investigated this and two previous complaints, this wasn’t something she’s asked our service to review. And, as she’s brought the complaint to us as a representative of Mr F’s estate, I couldn’t direct L&G make her any award in her personal capacity. So it’s not something I’ve commented on. I’m not a doctor. So I can’t decide what caused Mr F’s liver issues. My role is to decide whether the decision L&G made was reached fairly and reasonably, taking into account the available evidence and the relevant law. The relevant law in this case is 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 the qualifying misrepresentation was deliberate or reckless, or careless. In this case, there is no direct evidence of how much Mr F was drinking when he applied for the policy in summer 2020. L&G say the records show that he was drinking much more than he declared just a few months after the application. And that the identification of a fatty liver, and subsequent diagnosis of cirrhosis in late 2021, is consistent with heavy alcohol consumption over a sustained period - which can’t be attributed to an increase in Mr F’s consumption following his retirement around the time of the application. Mrs F says that Mr F’s liver issues could have had other causes and there is no evidence that he was drinking more than he said he was before or at the time of the application. She’s provided two letters containing an assessment of the records from a consultant gastroenterologist in support of this. I’ve reviewed the medical evidence on file. I can see that, in early October 2020, Mr F sought medical advice, having suffered from gastrointestinal issues for 7-8 weeks. This resulted in a referral for investigations. The consultants conducting those investigations

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referred in November 2020 to him drinking 4-5 pints a day, and that he had a very fatty liver which was: “…very likely to be due to your high alcohol consumption, which clearly must be reduced dramatically.” There are a number of other entries referring to Mr F consuming more alcohol than he should, and needing to cut down. If L&G had simply relied on these entries and on the fact that Mr F went onto develop cirrhosis in 2021, I don’t think it would have been fair for them to say he made a misrepresentation on his application. But I can see that they asked their Chief Medical Officer (CMO) to review the available records. And they’ve shared the CMO’s opinion, which I’ve considered. The CMO has stated that the findings of Mr F’s consultants in late 2020 couldn’t plausibly have arisen if Mr F had only started drinking heavily in the previous summer. They say the type of liver function test results he had typically require years of excess. And that is also the case for progression from fatty liver to cirrhosis. The CMO concluded from this that Mr F was drinking more than he declared at the time of his application. I’m satisfied from this that L&G based their decision on the advice of a medical expert. I’m aware that Mrs F has submitted that alcohol consumption isn’t the only cause of either fatty liver or cirrhosis. I can see there was a period of a few months when Mr F was treated for haemochromatosis, which can cause liver issues. But tests to see if this was genetic were negative. And I’ve not seen anything in his medical records that shows another cause was identified. In those circumstances, I can’t say L&G’s conclusion that his illness was the result of sustained alcohol intake was unreasonable. Mrs F provided two letters from a consultant gastroenterologist to support her position. These were shared with L&G who asked their CMO to comment. The CMO has noted that these letters show Mr F had a fatty liver in 2019 and that, in 2018, he had similar symptoms to those he had in 2020 and which led to his eventual diagnosis with cirrhosis. In his view, this bolsters his conclusion that Mr F must have been drinking more than he disclosed in his application. As I’ve said, I can’t decide which doctor was right. But I am more persuaded by the CMO’s opinions than by the medical evidence supplied by Mrs F. I think it was fair for L&G to rely on their CMO’s opinion. And I think it was fair for them to conclude, based on that opinion, that Mr F didn’t accurately disclose his alcohol intake in his application and so made a misrepresentation. I think that was a qualifying misrepresentation because L&G have provided documentary evidence which shows that, if Mr F had disclosed he was drinking the amount their CMO concluded he must have been, they wouldn’t have offered him the policy. Finally, I’ve noted that L&G categorised Mr F’s misrepresentation as careless. CIDRA sets out that, where there’s been a careless misrepresentation, how they should deal with it depends on what they would have done if they’d received accurate information at the time of sale. In cases, like this, where an insurer wouldn’t have sold the policy at all, CIDRA says they can avoid the contract and refuse any claim. But they must return the premiums the customer paid.

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That’s what L&G did here. As they’ve complied with CIDRA, I can’t say they should do anything else to resolve the complaint Mrs F’s made on behalf of the late Mr F’s estate. My final decision For the reasons I’ve explained, I’m not upholding the complaint Mrs F has made about Legal and General Assurance Society Limited on behalf of Mr F’s estate. Under the rules of the Financial Ombudsman Service, I’m required to ask the estate of Mr F to accept or reject my decision before 22 May 2026. Helen Stacey Ombudsman

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