Not upheld: unfair claim refusal / failure to assess medical evidence fairly complaint against Legal and General Assurance Society Limited
Financial Ombudsman decision DRN-6196535 of 2026-05-20T00:00:00+00:00. unfair claim refusal / failure to assess medical evidence fairly complaint against Legal and General Assurance Society Limited. Outcome: Not upheld.
Decision detail
| Reference | DRN-6196535 |
|---|---|
| Decision date | 2026-05-20T00:00:00+00:00 |
| Firm | Legal and General Assurance Society Limited |
| Product | income protection insurance |
| Claim type | unfair claim refusal / failure to assess medical evidence fairly |
| Outcome | Not upheld |
| Remedy | None. The ombudsman declined to uphold the complaint and did not ask L&G to revise its decision or pay the claim. Miss P was advised she could submit additional evidence such as vocational clinical assessments to L&G for reconsideration. |
Summary
Miss P claimed income protection benefit after being signed off sick from January 2023 with anxiety, depression and cognitive issues. L&G refused the claim, stating personal life challenges rather than illness drove her incapacity. After the first complaint was closed by FOS in October 2024, Miss P obtained a psychiatric report diagnosing recurrent depressive disorder and ADHD, which she submitted to L&G. L&G again refused, with its Chief Medical Officer noting the report provided no new evidence for the deferred period and that the long-standing nature of Miss P's conditions did not explain her sudden inability to work. The ombudsman upheld L&G's decision, finding that Miss P had not demonstrated illness was the primary reason for incapacity during the relevant period, and that Dr S's report did not provide the necessary retrospective functional assessment required by the policy definition.
The Ombudsman's reasoning
The ombudsman applied the policy definition requiring Miss P to demonstrate that illness was the primary reason for incapacity and prevented her from performing essential duties of her occupation immediately before the start of the deferred period. While acknowledging Miss P's debilitating symptoms, the ombudsman found that Dr S's report did not provide retrospective assessment of her functional capacity during the January-July 2023 deferred period, instead concentrating on overall medical history. Critically, Dr S noted Miss P's mental health conditions as long-standing and present throughout her adult life, which did not explain why she could no longer work from January 2023 when she had previously managed her occupation despite ongoing mental health symptoms. The ombudsman concluded L&G fairly assessed the medical evidence and reasonably determined the policy definition had not been met.
How this compares
| Group | Decisions | Uphold rate |
|---|---|---|
| Legal and General Assurance Society Limited, all decisions | 1,099 | 18% |
Source
Read the original decision on the Financial Ombudsman Service website