Not upheld: claim rejection / failure to pay claim complaint against Aviva Protection UK Limited

Decision detail

Summary

Mr R claimed under a group income protection insurance policy for anxiety and depression but Aviva rejected the claim, stating he had not met the threshold for payment. The claim was also notified late (outside the 90-day requirement), though Aviva assessed it regardless. The ombudsman reviewed the available medical evidence including GP Statements of Fitness for Work, an ESA Support Group letter, and a psychotherapist's report. Finding this evidence insufficient to demonstrate Mr R was entirely unable to perform his usual occupation due to illness as required by the policy definition of 'incapacity', the ombudsman upheld Aviva's decision to reject the claim and did not uphold Mr R's complaint.

The Ombudsman's reasoning

The ombudsman applied the policy definition of 'incapacity' requiring Mr R to demonstrate he was unable to perform the material and substantial duties of his usual occupation due to illness throughout and beyond the deferred period. While acknowledging Mr R was unwell, the ombudsman found the available medical evidence was not persuasive enough to demonstrate such complete incapacity. GP Statements of Fitness for Work were considered limited in detail and based on self-reported symptoms. The psychotherapist's report, while relevant, was also limited in detail and when considered with medical records did not demonstrate the required incapacity. The ombudsman noted that different policy types have different thresholds and that the ESA Support Group threshold differs from income protection insurance requirements.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website