Not upheld: claim handling - benefit cessation decision and assessment of incapacity complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Ms F complained that Legal and General Assurance Society Limited unreasonably ceased paying full income protection insurance benefit in September 2022, arguing that the alternative occupations identified were unsuitable and that she was unable to work. Legal and General commissioned an independent occupational health physician's report which concluded Ms F could work 14-20 hours per week in an alternative occupation, and offered to pay benefit equal to 14 hours per week backdated. The ombudsman found it was not unreasonable for Legal and General to rely on this independent medical opinion and the transferrable skills analysis identifying suited occupations, despite conflicting evidence from Ms F's treatment providers. The ombudsman rejected Ms F's arguments that the occupations were unsuitable and that the impact on her personal life should be considered, finding the policy focused solely on ability to perform material and substantial duties of a suited occupation.

The Ombudsman's reasoning

The ombudsman found that Legal and General fairly relied on the independent occupational health physician's report (X) which concluded Ms F could work 14-20 hours per week in a suited occupation. Although there was conflicting medical evidence from Ms F's treatment providers, the ombudsman considered X to be an independent expert with relevant medical expertise who had access to all available evidence and had properly considered the witness statements. The ombudsman found the transferrable skills analysis appropriately identified suited occupations based on Ms F's experience, training and education, and that the policy terms clearly state suited occupations need not be comparable in pay, status or seniority to the insured's own occupation. The ombudsman rejected Ms F's argument that the impact on her personal life should be considered, as the policy focuses solely on ability to carry out material and substantial duties of an occupation.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website