Guides › Insurance Claims and Complaints › Critical Illness Claim Refused
Critical Illness Claim Refused
Critical illness claims are often refused because the insurer says the illness does not meet the policy definition, or that you did not disclose something when you applied. The Financial Ombudsman looks at the policy, the medical evidence and whether the insurer was clear about cover. Refusing for a mistake on the application is often unreasonable unless strict tests are met.
At a Glance
Your Rights
What the rules say, with a link to the official source for each.
Critical Illness Claims
Common Complaints
Complaints include the insurer saying the illness isn't covered by the policy definition (for example a heart attack not severe enough) or that the consumer didn't disclose certain information. The Ombudsman considers the law and rules at the time, the policy type, medical evidence from both sides, whether the insurer followed ABI guidelines and whether it was clear about what is covered. source
Your Rights
Misrepresentation
For consumer policies, an insurer rejecting a claim because of a misrepresentation is generally unreasonable unless it was a 'qualifying misrepresentation': you failed to take reasonable care not to misrepresent, and the insurer can show it would not have written the policy at all, or only on different terms, without it. source
Prompt and Fair Claims
The FCA's rules say an insurer must handle claims promptly and fairly, give you reasonable guidance to help you make a claim and appropriate updates on progress, not unreasonably reject a claim, and settle claims promptly once settlement terms are agreed (ICOBS 8.1.1R). source
Time Limits to Know
Miss a deadline and you can lose a right. Check the dates on your own paperwork.
- 8 weeksInsurer's time to give a final response to a complaint8 weeks for most complaints
- 6 monthsRefer a complaint to the Financial Ombudsman ServiceWithin 6 months of the date on the insurer's final response
Steps to Take
Step 1 of 5
Ask for the refusal reason in writing and the policy definition used.
Step 2 of 5
Get your medical records and a letter from your specialist.
Step 3 of 5
Check the questions you were asked when you applied.
Step 4 of 5
Complain in writing. We do not take insurance or banking complaints as cases, but our free letter templates can help you write to the firm.
Step 5 of 5
After 8 weeks, or a final response, go to the Financial Ombudsman Service.
(Tap the numbers to reveal steps)
Where to Go If It Is Not Put Right
Your options, in order, and when each one applies.
The Insurer's Complaints Team
Always start here, in writing.
Financial Ombudsman Service
After 8 weeks with no final response, or if you are unhappy with it. Refer within 6 months of the final response.
Good to Know
Small things that make your complaint stronger.
Read the definitions section of your policy: claims turn on the exact wording.
Want Help?
If you would like one of our team to look at your problem, our initial case review is free. We cannot guarantee any outcome and we do not give legal advice.
Lead reviewer
Luke Marley
Founder and Lead Reviewer
Luke founded CPUK in 2026 after seeing how hard it is for ordinary people to get problems with companies put right. He oversees our guides and checks them against official sources.
Research by Katie Burt, Co-founder and Operations Lead (17 years in the care sector, including managing services for vulnerable adults), and the CPUK Research Team. Researched with AI-assisted research tools, then checked and corrected by our team.
Last checked: 13 October 2026. We are not paid by the companies we write about. Adverts never affect our guidance. Read our editorial policy.
Sources and official links
- financial-ombudsman.org.uk/consumers/complaints-can-help/investments/critical-illness-cover Checked 13 October 2026
- handbook.fca.org.uk/handbook/icobs8 Checked 12 October 2026
- financial-ombudsman.org.uk/consumers/complaints-can-help/expect/time-limits Checked 12 October 2026