Critical Illness Claim Refused by Insurance Co – Type 1 Diabetes, FCA Breaches & Neurodiversity Conc

NotNigel

@user1977 @dunstonh @DullGreyGuy @HappyHarry
Thank you to everyone who’s taken the time to respond. I’ve learned a lot from your insights and appreciate the chance to clarify the key issues — particularly the misunderstanding around the focus of my complaint.

This is not a dispute about whether Royal London were obligated to automatically upgrade me or notify me of every new policy. I accept that insurers regularly update products and don’t typically transfer existing customers onto new terms. That’s normal.

However, my complaint is not centred on that point. The core issue is as follows:

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 1. Royal London Did Not Provide the Policy Terms and Conditions (T&Cs)

• I requested the full T&Cs twice before I made a claim.

• On both occasions, Royal London instead sent me a different document (Terms of Acceptance).

• I have saved, time-stamped emails proving this.

• Only after my claim was declined did they send the full T&Cs — which included the list of critical illnesses and exclusions.

I flagged this to the Ombudsman, who still concluded that the T&Cs were “probably sent” — despite:

• A Royal London representative admitting in writing that “they probably weren’t sent as customers don’t usually request them,” and

• Royal London being unable to retrieve the original emails, citing GDPR restrictions.

This is not speculative — I have concrete evidence showing that the document I requested and was entitled to (under ICOBS 6.1.5R) was not provided.

It is not reasonable or in line with FCA rules to place the burden on the customer to identify that they were sent the wrong document — particularly in a non-advised sale through an aggregator, with no ongoing financial adviser.

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2. Relevance of FG16/8 and ‘Closed Book’ Products

Yes, FG16/8 was primarily issued for investment-type products. However, the FCA’s own wording says:

“Product providers and intermediaries should also consider the guidance in informing their practices and processes in respect of all products, including actively marketed products, in which long-standing customers are invested, as many of the same issues will arise.”

Royal London have withdrawn the version of the policy I bought and replaced it with a materially enhanced one. I could not buy my original product again today. I accept this may not be a technical “closed book,” but it is no longer available to new customers — and in Royal London’s own internal correspondence, it was referred to as a “closed product.”

Even if the guidance doesn’t strictly apply, the spirit of the FCA’s Principles does — especially Principle 6 (“Treat customers fairly”) and Principle 7 (“Communicate in a way that is clear, fair, and not misleading”).

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 3. Equality Act and Vulnerable Customer Considerations

• Once Royal London were notified of my Type 1 Diabetes, they knew I had a condition recognised as a disability under the Equality Act 2010.

• Separately, I informed the Ombudsman of my neurodivergence (ASD) diagnosis during the complaints process.

• Despite this, the tone and structure of the final response failed to make reasonable adjustments for how I decode logic and follow argument, which is relevant to how the decision was interpreted.

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In Summary:

This is not about asking Royal London to backdate cover or automatically upgrade my policy. It’s about:

 Factual failure to provide requested documentation
 Factual evidence being ignored in favour of unverified assumptions
 Poor communication that materially disadvantaged me
 Reasonable adjustments not being meaningfully made after a declared diagnosis

Thanks again to those who've contributed constructively. It’s appreciated.

caprikid1

Unfortunately I highly doubt you have a claim.

Really simple, you took out a policy with specific conditions covered, then you had a condition not covered by your policy. Happens all the time with CIC policies

DullGreyGuy

NotNigel said:

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2. Relevance of FG16/8 and ‘Closed Book’ Products

Yes, FG16/8 was primarily issued for investment-type products. However, the FCA’s own wording says:

“Product providers and intermediaries should also consider the guidance in informing their practices and processes in respect of all products, including actively marketed products, in which long-standing customers are invested, as many of the same issues will arise.”

Royal London have withdrawn the version of the policy I bought and replaced it with a materially enhanced one. I could not buy my original product again today. I accept this may not be a technical “closed book,” but it is no longer available to new customers — and in Royal London’s own internal correspondence, it was referred to as a “closed product.”

Even if the guidance doesn’t strictly apply, the spirit of the FCA’s Principles does — especially Principle 6 (“Treat customers fairly”) and Principle 7 (“Communicate in a way that is clear, fair, and not misleading”).

You are not investing into a critical illness policy, you are just paying premiums. FG16/8 is about investment based products, some explicitly named for which the guidance strongly applies and some unnamed in which it less strongly applies.


You ultimately chose to do a non-advised purchase for a fairly complex product. As such it is up to you to determine if the product is suitable for your needs or if there are better products on the market, that includes at point of sale but also at later stages too. The fact you bought from an aggregator would suggest you valued price above other factors. 

As the Ombudsman has confirmed in other cases, there is no duty on an insurer to tell existing customers when new versions of the product come along. As a direct insurer they are non-advisory and if a firm were to tell customers of new products they would be walking a very thin line to ensure they arent seen as making a recommendation of the new product over the old. In many cases the products are simply different with some new things covered but some old things not covered or criteria changed. 

If you want someone to keep an eye on the market for you and tell you when new products are launched or someones got improved pricing etc you need to go down the advised sale route and that will never be directly with the insurer (though some insurers do have an advisory sister company) 

NotNigel

Thank you again to everyone for the responses – I genuinely appreciate all input, even where we disagree. But I’d like to respectfully clarify the actual basis of my complaint, which I feel is being misunderstood or misrepresented.

This is not just about whether newer policies are automatically offered to older customers, or whether I could have found one on my own. I understand that critical illness cover is a non-advised product and that terms evolve.

But here’s what my complaint is actually about:

1. Failure to Provide the Contract (Terms and Conditions) – Twice

Before my diagnosis and claim, I requested the Terms and Conditions twice (in 2022 and again in 2024). Both times, Royal London sent me the wrong document — a “Terms of Acceptance” summary, not the full contract.

I didn’t know it was the wrong document — because, as a layperson, I’m not expected to. I relied on Royal London’s communication to be clear, accurate, and fair.

Only after my claim was declined did they finally send the full policy and exclusions — months after I’d specifically asked for it.

In one email, Royal London even admitted that the T&Cs were “probably never sent, as customers don’t usually request them.” So there’s no dispute that I asked, and that they failed to send them.

Why this matters:

 This is a clear breach of several FCA rules:

• ICOBS 6.1.5R – firms must provide appropriate, comprehensible, and timely information so the customer can make informed decisions.

• ICOBS 2.2.2R – firms must act honestly, fairly and professionally in accordance with the best interests of their customer.

• FCA Principles 6 & 7 – fair treatment of customers and clear, not misleading communications.

• Consumer Rights Act 2015 (Section 68) – contract terms must be transparent and prominent.

If I don’t receive the actual T&Cs after specifically asking for them — twice — how could I possibly know what my policy covered or excluded?

It’s not realistic to expect a customer to spot the difference between an “acceptance letter” and the full legal policy when nothing in the communication says, “This is not your T&Cs.”

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 2. Regulatory Context and Consumer Expectations

Some posters have said it’s my responsibility to review the market or switch policies. I accept that in part. But the regulator has been clear — especially in guidance like FG16/8 — that firms should review older policies when updates may lead to better outcomes, and communicate that to customers, especially if they remain on now-withdrawn products.

Whether or not my product is a “closed book” in the technical sense, it is no longer for sale, and Royal London themselves referred to it internally as a “closed product.” There is at least an ethical and fairness-based obligation here, if not a regulatory one.

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 3. My neurodiversity and vulnerable customer considerations

I have been diagnosed as autistic (ASD). I made the FOS aware of this before their final decision. Despite that, I received no tailored communication, no clarification of how my evidence had been considered, and no adjustments made to ensure I understood the rationale behind the decision — which was confusing and distressing.

Under the Equality Act 2010 and FCA FG21/1 (Vulnerable Customers), both Royal London and the Ombudsman had duties to consider how my condition might affect my ability to engage in a complex dispute process and to make reasonable adjustments. That didn’t happen.

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This isn’t about wanting cover I didn’t pay for. It’s about:

• Being misled (however unintentionally) by Royal London’s failure to send the actual terms;

• Being disadvantaged because I wasn’t told about newer policies when mine was no longer sold;

• And then having the FOS accept the insurer’s assumptions over my documented evidence — without explanation — despite my vulnerable status.

If anyone has had a similar situation or found a solicitor or advocate who understands this kind of regulatory breach and how vulnerable customers are meant to be treated, I’d be grateful for a recommendation.

Thanks again for your time.

XRS200

What outcome are you seeking?

dunstonh

Before my diagnosis and claim, I requested the Terms and Conditions twice (in 2022 and again in 2024). Both times, Royal London sent me the wrong document — a “Terms of Acceptance” summary, not the full contract.
I didn’t know it was the wrong document — because, as a layperson, I’m not expected to. I relied on Royal London’s communication to be clear, accurate, and fair.
Only after my claim was declined did they finally send the full policy and exclusions — months after I’d specifically asked for it.
In one email, Royal London even admitted that the T&Cs were “probably never sent, as customers don’t usually request them.” So there’s no dispute that I asked, and that they failed to send them.

The retailer would have had them available to provide to you at point of sale to download.

Why this matters:
 This is a clear breach of several FCA rules:
ICOBS 6.1.5R – firms must provide appropriate, comprehensible, and timely information so the customer can make informed decisions.
ICOBS 2.2.2R – firms must act honestly, fairly and professionally in accordance with the best interests of their customer.
FCA Principles 6 & 7 – fair treatment of customers and clear, not misleading communications.
Consumer Rights Act 2015 (Section 68) – contract terms must be transparent and prominent.
If I don’t receive the actual T&Cs after specifically asking for them — twice — how could I possibly know what my policy covered or excluded?
It’s not realistic to expect a customer to spot the difference between an “acceptance letter” and the full legal policy when nothing in the communication says, “This is not your T&Cs.”

Royal London did not retail the product to you.  So, they are not responsible for the documentation provided at prior to or at point of sale.

Some posters have said it’s my responsibility to review the market or switch policies. I accept that in part. But the regulator has been clear — especially in guidance like FG16/8 — that firms should review older policies when updates may lead to better outcomes, and communicate that to customers, especially if they remain on now-withdrawn products.
Whether or not my product is a “closed book” in the technical sense, it is no longer for sale, and Royal London themselves referred to it internally as a “closed product.” There is at least an ethical and fairness-based obligation here, if not a regulatory one.

As already stated on this thread, that does not apply here.

A closed product is not the same as a closed book.

3. My neurodiversity and vulnerable customer considerations
I have been diagnosed as autistic (ASD). I made the FOS aware of this before their final decision. Despite that, I received no tailored communication, no clarification of how my evidence had been considered, and no adjustments made to ensure I understood the rationale behind the decision — which was confusing and distressing.
Under the Equality Act 2010 and FCA FG21/1 (Vulnerable Customers), both Royal London and the Ombudsman had duties to consider how my condition might affect my ability to engage in a complex dispute process and to make reasonable adjustments. That didn’t happen.

None of that applies to point of sale, which Royal London were not involved or any point up to you told them.   It is entirely possible that individual staff members don't have a clue about how they would need to deal with you specifically unless you told them.   These people are not doctors.  They will draw on experience and training which will be to listen and examine your communications.  

This isn’t about wanting cover I didn’t pay for. It’s about:
Being misled (however unintentionally) by Royal London’s failure to send the actual terms;
Being disadvantaged because I wasn’t told about newer policies when mine was no longer sold;
And then having the FOS accept the insurer’s assumptions over my documented evidence — without explanation — despite my vulnerable status.
If anyone has had a similar situation or found a solicitor or advocate who understands this kind of regulatory breach and how vulnerable customers are meant to be treated, I’d be grateful for a recommendation.

You are seeing regulatory breaches where there are none.

You are expecting a manufacturer to carry out the duties that the retailer is meant to do.  That isn't how it works.  If you had bought the product direct from Royal London, then it would have a duty as a retailer to make the documentation available to you at or prior to sale.   

If you were paying a company to provide the ongoing services you are after then that company has a duty to you.   However, you bypassed the companies that can do that sort of thing to take on that responsibility yourself.    Royal London does not provide that service and you haven't paid Royal London to provide that service.

DullGreyGuy

NotNigel said:

 I understand that critical illness cover is a non-advised product and that terms evolve.

No product is inherently advised or non-advised, my protection products were all bought on an advised sales basis because I wanted, and felt I needed, the advice of a specialist rather than choosing to go down the non-advised sale route. You had the same choice but decided you wanted non-advised.

NotNigel said:

• Being disadvantaged because I wasn’t told about newer policies when mine was no longer sold;

No matter how many times you repeat it it won't change the reality that they dont have to inform pure insurance customers about new products any more than Apple has to tell you when there is a new iPhone or Barrett when they are putting up a new development of houses.

It may have been is you had an advisor they would have

NotNigel said:

1. Failure to Provide the Contract (Terms and Conditions) – Twice

You dont say which aggregator you used but there will have been an intermediary that they introduced you to; if you used Money Supermarket, as the owners of this site, for example then its LifeSearch that sold you the policy and its them that should have provided you with the T&Cs.

NotNigel

@XRS200 it would be great if they paid my Critical Illness 

NotNigel

@dunstonh @DullGreyGuy The way the aggregator worked (Neilson, through GoCompare) was that they, online, showed me a list of policies and I clicked on the one I felt was best for me. I never spoke to anyone at these companies and they introduced me to Royal London as opposed to retailing or selling me anything. I went straight to RL who then discussed various options, underwrote the policy and then sold it to me. In fact, the CI was upsold as I had initially only enquired about Life Insurance but on the recommendation, or sales patter, from RL, upgraded the policy to include CI. Neilson never sold me anything. The retailer was 100% RL and therefore must be responsible for sending me clear T&Cs. I requested them twice from RL and on both occasions they sent me (what I now know to be) Terms of Acceptance. They never advised me that they weren't the T&Cs and actually responded by saying 'here is the document you requested.' Never did they say request this from GoCompare as they are the retailer, they took full responsibility for sending me, what turned out to be, the wrong docs.

My belief is these are the breaches, as per the above
ICOBS 6.1.5R – firms must provide appropriate, comprehensible, and timely information so the customer can make informed decisions.
ICOBS 2.2.2R – firms must act honestly, fairly and professionally in accordance with the best interests of their customer.
FCA Principles 6 & 7 – fair treatment of customers and clear, not misleading communications.
Consumer Rights Act 2015 (Section 68) – contract terms must be transparent and prominent.

The fact I have email trails from RL showing they sent me misleading comms and non-transparent and prominent terms represents a breach.

Neilson have also sent me an email advising that their terms and conditions with RL allow them to only provide an introductory service and have no remit for sales. As much as RL want to blame someone else for not providing appropriate information to allow me to make informed decisions it is their responsibility to uphold the above guidelines.