Was your critical illness cover mis-sold?

A declined claim can expose a problem with the sale, but it does not prove one. The useful starting point is to identify what went wrong, who was responsible and what evidence supports it. The sale and the claim may need separate answers, even for the same policy.

Updated 11 November 20267 min read

At a glance

  • A declined claim does not automatically prove the policy was mis-sold.
  • The seller and the insurer may be responsible for different problems.
  • Sales records and claim evidence answer different questions.
  • The Financial Ombudsman Service is free for consumers to use.

Mis-sold critical illness cover or an unfair claim decision?

A sale complaint asks what you were told and whether the cover suited the needs assessed at the time. A claim complaint asks whether the insurer treated your claim fairly under the contract. The same experience can raise both issues.

An illness outside the policy's list does not automatically make the original sale wrong. Nor does having a list of exclusions, meaning situations the policy leaves out. The question is how the cover was described and, where advice was given, whether the recommendation was suitable.

The Financial Ombudsman Service considers both the sale and the handling of claims. Its guidance describes complaints about explanations, medical assessments, application answers and delays. It does not establish that one unsuccessful claim proves any of those failings.

For the normal claim process, see how to claim on critical illness cover. A complaint should identify the disputed action rather than simply say that insurance ought to have paid. That gives the business something specific to investigate.

What can show that the sale went wrong?

Relevant issues can include an inaccurate explanation of the illnesses covered or an unsuitable recommendation. A seller might also have presented optional cover as something you had to buy. Each allegation needs the circumstances and available evidence behind it.

There is a difference between an advised sale, where someone recommended cover as suitable, and a sale without a personal recommendation. The information provided still matters in either case. The Ombudsman examines the sales process rather than assuming every purchase involved advice.

An existing policy does not automatically make a second one unnecessary. Different cover can serve different needs, and more than one critical illness policy can sometimes pay. What matters is what the seller knew, what was needed and what the new cover was meant to achieve.

The guide to getting advice on critical illness cover explains the normal suitability discussion. In a complaint, the useful evidence is the record of your circumstances then. A later change in your needs does not by itself show that the original sale was unsuitable.

A replacement policy needs the old paperwork too

Ruth is a fictional teaching assistant in Nottingham who was advised to replace her policy. Later, a claim is declined because the replacement excludes a condition included in her earlier cover. She remembers being told that the new policy gave her the same protection.

Her sale complaint needs both sets of terms and the explanation for the switch. Her claim complaint needs the replacement policy's definition and the insurer's reason for declining payment. A definition is the written medical or procedural test that a claim must meet.

The Ombudsman's guidance specifically considers replacement cover that leaves someone with less protection. It looks at whether the customer understood the change and why it was recommended. A reduction in the amount paid for insurance is not, by itself, a sufficient reason to restrict cover.

Ruth's account matters, but it does not establish an outcome on its own. The recommendation letter, call recording and original schedule could support or contradict it. The schedule is the document showing the particular cover and any individual terms applied to her policy.

A rejected claim still needs its own evidence

Ben, a fictional warehouse supervisor in Cardiff, has a heart attack and stops working. His insurer says the medical evidence does not meet his policy's heart attack definition. That creates a question about the claim assessment before it establishes anything about the sale.

The insurer's explanation should identify the relevant wording and why it says the evidence falls short. A complaint can challenge that reasoning or the evidence used. Being unable to work does not, on its own, establish a listed critical illness claim.

In published decision DRN-5285441, the Ombudsman considered a declined claim and an allegation of mis-selling separately. The condition was outside that policy's list, and the available sales evidence did not establish a mis-sale. Neither part of the complaint was upheld, meaning neither was accepted.

That decision illustrates the distinction rather than predicting another person's outcome. The guide to critical illness definitions explains why wording matters. The Ombudsman also considers fairness and the evidence as a whole, rather than treating a rejection letter as the last word.

What if the insurer says an application answer was wrong?

An insurer may say that an incorrect or incomplete answer affected the cover it offered. This is often called misrepresentation. It raises different questions from whether a diagnosis meets a condition definition.

The Ombudsman's current guidance looks at the exact question, the answer given and whether reasonable care was taken. It also checks whether correct information would have changed the insurer's decision. The applicable rules depend on when the contract was made, and an error does not automatically justify every response an insurer might take.

If an adviser completed the application, the recording and completed answers can help establish what happened. The consumer's account of what they disclosed is relevant too. The evidence may raise a complaint about the seller, the insurer's response or both.

In a dispute, useful records include the application as submitted and any request to check its accuracy. The insurer's explanation should show why the disputed answer mattered. A protection specialist can explain application requirements, but a complaint about past conduct needs the relevant business to address what actually happened.

Build a complaint around the missing evidence

A short chronology helps connect the sale, any replacement and the claim. It can record when you bought the policy, what you understood it to do and when you discovered the problem. Dates and your own account are more useful than copied legal language.

The supporting records depend on the issue.

  • For the sale, the needs assessment, recommendation letter, application and any call recording.
  • For a replacement, the earlier policy and the explanation of what would change.
  • For a declined claim, the policy wording, rejection letter and relevant medical evidence.
  • For the effect on you, a record of losses, delays or avoidable distress caused by the disputed conduct.

Missing paperwork does not mean there is nothing to investigate. The business may hold records you no longer have, and the Ombudsman considers accounts from both sides. In the published decision above, it assessed the limited surviving sales evidence alongside the complainant's account.

The complaint can state what you believe should put matters right without assuming a particular payment is due. Any uncertainty about what happened should stay visible. Adding a claim you cannot support can distract from a point that the records do establish.

Who receives the complaint and what happens next?

A complaint about a recommendation normally goes to the business responsible for the sale. A complaint about an insurer's decision normally goes to the insurer. These may be different businesses, even though there is only one policy number.

Where both are involved, each can be told which part of its conduct is disputed. Ruth's seller would need to address the replacement recommendation. Her insurer would need to address its assessment of the claim under the replacement contract.

The usual route begins with the business, giving it a chance to investigate. Its final response is the letter setting out its decision and the right to refer the complaint further. For this type of complaint, the usual response period is eight weeks.

If that period passes without a final response, or the response is unsatisfactory, the Financial Ombudsman Service can consider whether it can help. Consumers can use it free of charge without employing a solicitor or claims company. A friend or family member can also help with the complaint.

The complaint deadlines and possible outcomes

The usual time limit for complaining to the business is six years from the event. If later, it is three years from when you knew, or reasonably ought to have known, you had cause to complain. These are separate from the usual six months to approach the Ombudsman after the date of the final response.

Exceptional circumstances and other exceptions can affect those limits, so the Ombudsman decides disputed timing. Very old sales can also raise questions about which businesses and events its powers cover. Its guidance says it can generally consider insurance advice and arranging complaints about events from 14 January 2005, with circumstances affecting earlier cases.

The remedy depends on the failing and loss established. An unfairly declined claim may lead to payment with interest. A mis-sale may lead to a refund of payments made for cover, or a remedy involving an earlier policy that should not have been replaced.

Compensation for avoidable distress or inconvenience may also be considered, but none of these outcomes follows automatically. Cancelling cover is a separate decision that can remove protection while the complaint remains unresolved. A complaint itself does not require you to cancel the policy.

Questions people ask

How do I know if my critical illness cover was mis-sold?

Relevant evidence can include what you were told, the needs assessed, the recommendation and the policy terms. A declined claim or an illness outside the list does not prove mis-selling on its own.

Can I complain about mis-sold critical illness cover without making a claim?

Yes, a complaint can concern the sale itself. It still needs a specific explanation of what went wrong, and the relevant complaint time limits apply.

Who do I complain to about mis-sold critical illness cover?

The starting point is the business responsible for the sale. A separate complaint about the insurer's claim decision normally goes to the insurer, and unresolved complaints may then go to the Financial Ombudsman Service.

Can I get my money back for mis-sold critical illness cover?

A refund is one possible remedy if a mis-sale is established, but it is not automatic. The outcome depends on the evidence, the failing and how you lost out.

Do I need a claims company for a critical illness complaint?

No, consumers can complain to the business and use the Financial Ombudsman Service without paid representation. A friend or family member can help if you want support.

How long do I have to complain about mis-sold critical illness cover?

The usual business complaint limit is six years from the event or, if later, three years from actual or reasonably expected awareness of cause to complain. The Ombudsman referral deadline is normally six months from the date of the final response, and exceptions can apply.

Sources

We checked this guide against these sources. It is general information, not advice.

Related guides

All guides