Not upheld: claim rejection — failure to meet policy definition of incapacity complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Mrs H claimed income protection insurance benefits after falling ill with chest pain and undergoing cancer investigations, resulting in being signed off work in 2024. L&G declined the claim, stating Mrs H had not demonstrated she met the policy definition of 'incapacity'. The ombudsman upheld L&G's decision, finding that while Mrs H was genuinely unwell, the available medical evidence did not persuasively show she was entirely unable to perform her job as required by the policy. The ombudsman noted that GP Statements of Fitness for Work and hospital appointments alone do not constitute sufficient evidence of incapacity under insurance policy terms. L&G's information requests were reasonable and its handling of the claim was fair, though L&G offered to reconsider a claim from a later date following Mrs H's 2025 surgery if she provided new evidence or cooperated with consent requests.

The Ombudsman's reasoning

The ombudsman applied industry rules requiring insurers to handle claims fairly and not unreasonably reject claims. The policy required Mrs H to demonstrate she met the definition of 'incapacity' — being entirely unable to carry out her job due to illness. While acknowledging Mrs H's genuine illness, the ombudsman found no persuasive medical evidence showing her functioning was restricted to the extent required by the policy. The ombudsman noted that GP Statements of Fitness for Work are based on self-reported symptoms and have a different threshold than insurance policy criteria. The ombudsman found L&G's information requests reasonable and that the delay in requesting information was not unreasonable given the timing of investigations. Factual errors in correspondence did not undermine the decision to decline the claim.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website