When critical illness cover is not paying out, the reason is often that the diagnosis did not meet the policy's wording for that condition; a wrong answer on the application, or a policy that had already ended, can also stop a claim. Most claims are paid, and a refusal can be challenged.

If you are buying cover, an FCA-authorised broker can check a policy's wording against your own health history on a free call-back; asking for that call takes only the form on this page. If you already hold a refusal letter, the last section explains how to take it to the Financial Ombudsman Service.

What share of critical illness claims are refused?

The Association of British Insurers (ABI), in its minimum standards for critical illness cover (updated April 2023), says more than 91% of claims were paid across the market in 2021, and that "There will inevitably be a small number of cases where a customer makes a claim for a condition which falls outside the scope of their cover."

For 2025, Aviva's release of 25 March 2026 reports a 90.7% payment rate on a combined group of critical illness, child and permanent disability benefits, and LV= says 90% of its critical illness claims were paid (July 2026). Aviva gives its main reason for the rest: "the majority were due to the customer’s diagnosis not meeting the policy definition for their condition." The ABI's 97.9% for 2025 covers individual life, income protection and critical illness policies together, and each insurer counts its own book differently. Critical illness claims statistics and life insurance claims statistics set out what each figure counts.

Why does a diagnosis sometimes fail to meet the policy definition?

A serious diagnosis and a policy definition are separate tests. The policy summary Legal & General publishes for its life and critical illness plan (QGI14786, October 2026, direct version) says: "For a claim to pay out, your illness must meet Legal & General's definition as found in the Policy Terms and Conditions." It warns that some types of cancer are not covered and that, for some illnesses, you need permanent symptoms. A UK consultant whose specialism the insurer considers appropriate must also confirm the diagnosis.

The ABI's model wording sets the minimum for cancer. Under it, a cancer has to be more than pre-malignant or in situ to count, borderline and low-potential tumours are left out, prostate tumours are excluded below a stated Gleason score or stage, while skin cancers are left out unless they are melanomas that have spread beyond the epidermis. An insurer may amend a model wording to increase cover, which is why one list can pay where another does not. See the ABI minimum standards, the conditions policies list and prostate cancer for the wording.

Whether a diagnosis you already have fits a particular insurer's wording is worth raising when the broker phones after your enquiry.

How does non-disclosure affect a critical illness claim?

Legal & General's summary says: "You are not covered if you don't give us full and accurate answers to the questions we ask you before the policy starts." Aviva's Critical Illness Plan policy conditions (DA09002, May 2023, from its adviser library) say that if information given "is untrue or incomplete and would have affected our decision to provide your policy", it may change the terms or premiums, or cancel the policy and refund the premiums paid, without interest. Cancelling means no claim can be made.

The Financial Ombudsman Service describes what an insurer might do when it finds a possible misrepresentation at claim stage: charge more, apply a restriction that could mean a later claim is declined, settle a claim proportionately, or avoid the policy. Its checks are whether the questions were clear and specific, whether you took reasonable care, and whether the correct answer would have changed what the insurer did. It also says it can be acceptable not to have told an insurer something you "don’t know or couldn’t reasonably have been expected to know".

The law is on life insurance disclosure requirements, and the wider grounds for refusing a life claim are set out in can a life insurance company refuse to pay. If a health question leaves you unsure how to answer, ask the broker who calls back, before any application is sent; medical questions for life insurance lists what tends to be asked.

What else can stop a critical illness policy paying?

A policy that has ended cannot be claimed on. Legal & General's summary says cover stops once 60 days have passed from the first missed premium, unless the policy expires inside that window, and that reaching the end of the term without a valid claim pays nothing. It also does not pay if death occurs within 14 days of diagnosis. When a life insurer can cancel a policy deals with how a policy ends.

Exclusions are the other route. The ABI guide gives model wordings for exclusions policies commonly use, such as alcohol or drug abuse, criminal acts, flying other than as a passenger in a commercially licensed aircraft, and hazardous sports, but does not require any insurer to include or omit a particular one. The policy schedule and terms you receive are what count.

What does the claim process involve, and how long can it take?

The time depends on the evidence. Aviva's policy conditions say it asks for proof of the critical illness, written consent to see medical information and test results, and reports from attending consultants, and that it pays for information it asks third parties to supply. The ABI guide adds that, for conditions which must be permanent to qualify, an assessment period will not normally be longer than 12 months, as long as all the evidence is available. When critical illness cover pays out covers the survival period and each step.

How do you complain to the Financial Ombudsman Service?

Start with the insurer. The Ombudsman says: "Before bringing your complaint to us, you should make a formal complaint to the company involved." The insurer has up to eight weeks to answer; once its final response is in, or if the time runs out without one, and you are not satisfied, the case can go to the Ombudsman. Keep the final response, because "We will ask to see it".

The deadline: "You will need to make a complaint to us within 6 months from the date on your final response." Late complaints can still be considered in exceptional circumstances, including a period of serious ill health or a bereavement. The service is free, and you do not have to pay anyone to represent you.

For critical illness, the complaint is often that the diagnosis did meet the definition, or that an answer was not a misrepresentation. The Ombudsman decides "using evidence from you, the financial business and any relevant third parties", so keep medical letters and the insurer's correspondence together.

If you are comparing policies now, the broker who rings you can explain how each definition would apply to someone in your position.

Frequently asked questions

Can you complain if the insurer says your illness does not meet the definition?

Yes. The Ombudsman describes complaints where an insurer "treated them unfairly by either not meeting their claim, or by altering the terms of their policy". It weighs the facts against the law, the regulator's rules, industry codes of practice and, where appropriate, good industry practice at the time.

What if the insurer's final response is more than six months old?

Usually the Ombudsman cannot help once six months have passed. Besides exceptional circumstances, it can still look at the complaint if the insurer never sent a valid final response, or if the insurer agrees to the Ombudsman being involved after the deadline.

Sources

  • Association of British Insurers, Guide to Minimum Standards for Critical Illness Cover (16 September 2022, updated April 2023), read 18 October 2026. abi.org.uk
  • Association of British Insurers, Protection insurers pay out £7.84 billion to help customers safeguard their finances (29 June 2026), read 26 October 2026. abi.org.uk
  • Aviva, Aviva paid nearly £2 billion in protection claims in 2025 (25 March 2026), read 26 October 2026. aviva.com
  • LV=, A look back at our 2025 claims (49891-2026 07/26), read 18 October 2026. lv.com
  • Legal & General, Life Insurance and Critical Illness Cover Policy Summary (QGI14786 - 2026/10; direct version), read 21 October 2026. legalandgeneral.com
  • Aviva, Critical Illness Plan Policy Conditions (DA09002 05/2023, adviser library), read 18 October 2026. static.aviva.io
  • Financial Ombudsman Service, Misrepresentation and non-disclosure, How to complain and Time limits (the Time limits page last updated 17 August 2022), all read 26 October 2026. financial-ombudsman.org.uk