Canada Life Limited · DRN-6189411

The complaint Mr M’s complained that Canada Life Limited (“CLL”) unfairly declined the claim he made on his group critical illness policy after he was diagnosed with cancer. What happened Mr M’s employer offers its employees the chance to opt into a group critical illness policy administered by CLL. Mr M opted in in late September 2024. Just a few weeks later, he was diagnosed with squamous cell carcinoma (SCC). So he contacted CLL to make a claim. CLL declined Mr M’s claim. They relied on an exclusion of pre-existing conditions which says: “No benefit will be payable for an insured illness (or a repeat of the same insured illness) which existed prior to the date of inclusion: • of the insured person or child in this Policy… • … If an insured person or child has suffered any form of cancer, as defined in Section 2 - What is covered, then no benefit will be payable in respect of any subsequent cancer whether or not the earlier cancer is connected to or associated with the subsequent cancer.” CLL said the medical records they’d reviewed to consider the claim showed Mr M had been diagnosed with polycythaemia vera (PV) in 2016 – which was a condition for which they would settle a claim under the “cancer” section of the policy. And they said that, although Mr M didn’t receive his SCC diagnosis until after he’d joined the scheme, he’d consulted his doctor about his symptoms in June 2024. So they said the exclusion applied. Mr M complained to CLL and provided a letter from his consultant saying the PV wasn’t a malignant cancer. CLL didn’t change their decision. So Mr M brought his complaint to the Financial Ombudsman Service. Our investigator reviewed the information provided by both parties and concluded CLL didn’t need to do any more to resolve Mr M’s complaint. He was satisfied that they’d made their decision in line with the policy terms and had applied the exclusion fairly. Mr M didn’t agree with our investigator’s view. So I’ve been asked to make a 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 Mr M’s complaint. I’ll explain why.

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I understand why Mr M’s upset. He’s been diagnosed with a condition which both parties agree would be covered by the policy. But CLL have applied the exclusion set out above. So I’ve focused on whether doing that was fair. CLL explained in their decline letter how the policy works. In common with many policies offered by employers as a benefit to their staff, no medical declarations are given by employees. Rather, the policy excludes cover for conditions that are pre-existing at the time an employee joins a scheme, or are related to a pre-existing condition. I’ve considered the exclusion set out above. I think it’s clear that, if someone has had any form of cancer before joining the scheme, all cancers are excluded from cover. Mr M has challenged CLL’s conclusion that his claim should be excluded because he was previously diagnosed with PV. To support what he’s said, he’s sent us a copy of a letter from a consultant haematologist, in which the consultant says: “This man has a background of a myeloproliferative condition. Although this can be associated with thrombotic complications if not controlled, which his is, and has a low risk (<10%) of transformation to leukaemia, this is not a malignant cancer.” I’ve considered this letter very carefully. While I note what the consultant has said, I’ve also seen that many sources of information about PV refer to it as a type of slow growing blood cancer. And CLL have confirmed they treat it as such when they receive a claim from someone with the condition. So I don’t think I can ask them to consider it differently here. And, even if I could, I don’t think it would make any difference for Mr M because CLL have also said that his SCC pre-dated him joining the scheme. Mr M has disputed this, and says he wasn’t diagnosed until October 2024. I’ve reviewed the available medical evidence. A medical report form completed by Mr M’s GP says he first consulted them in June 2024 about a number of skin lesions which were removed and found to be SCC in July. And they answered “yes” to a question asking if Mr M had previously had cancer or any pre-cancerous condition, saying he’d had basal cell carcinomas removed in late 2012 and early 2023. The records also include a referral letter from Mr M’s consultant dermatologist to his plastic surgeon (who removed the lesions) which confirmed that some may be cancerous. And there is a letter from the plastic surgeon to Mr M dated July 2024 confirming he’d removed both a basal cell carcinoma and a SCC. I appreciate the letter says the lesions were completely removed and no further treatment was necessary – and that Mr M didn’t know he needed treatment until after he joined the scheme. But the exclusion applies if a condition “existed” before then. The policy defines “existed” as: “an insured illness or related condition is said to have existed if it was: • first diagnosed, or • treated, or • known to the insured person or child prior to the date of inclusion….” I’m satisfied from the medical records that Mr M knew about, and was treated for, cancer before he joined the scheme. So I think it was fair for CLL to rely on the exclusion and decline his claim.

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Mr M has told us he now faces a difficult course of treatment which means he’ll no longer be able to work and will suffer financially as a result. I’m sorry my decision won’t help that situation. But, for the reasons I’ve explained, I don’t think CLL need to do anything more to resolve his complaint. My final decision For the reasons I’ve explained, I’m not upholding Mr M’s complaint about Canada Life Limited. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr M to accept or reject my decision before 8 April 2026. Helen Stacey Ombudsman

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