Not upheld: Home insurance claim disputes complaint against Assicurazioni Generali S.p.A UK Branch

Decision detail

Summary

Mr K complained that Generali unfairly declined his group income protection insurance claim. Mr K became absent from work due to workplace bullying and stress, and claimed a benefit under his GIP policy. Generali declined the claim, stating the absence was due to work-related stress rather than illness. The ombudsman reviewed the medical evidence, which consisted of GP fit notes and showed the absence was caused by workplace issues and stress. Finding no objective evidence of an illness preventing Mr K from performing his job duties, and noting that stress is a reaction to circumstances rather than an illness, the ombudsman upheld Generali's decision to decline the claim.

The Ombudsman's reasoning

The ombudsman applied the policy definition of incapacity which requires the member to be incapable of performing the material and substantial duties of their occupation due to illness or injury, and not carrying out any other work or occupation. The available medical evidence did not demonstrate an illness; instead it showed the absence was caused by workplace stress and bullying. Stress is a reaction to circumstances, not an illness. No confirmed diagnosis of a mental health condition was provided by a qualified medical professional. Even if a diagnosis existed, Mr K would still need to demonstrate inability to perform his job duties due to illness.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website