Not upheld: Home insurance claim disputes complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Mr M, a beneficiary of an employer group income protection scheme underwritten by L&G, claimed benefits following emergency surgery for a ruptured bowel in July 2024 that resulted in a stoma creation. The policy required 26 weeks of continuous incapacity before benefits became payable. L&G declined the claim in May 2025, arguing Mr M had not met the incapacity requirement for the full deferred period, as medical evidence suggested he could have started a phased return to work by October 2024 despite his GP certifying him unfit until January 2025. The ombudsman upheld L&G's decision, finding that while Mr M's condition was serious, the objective medical evidence showed steady recovery without complications, and the absence of specific functional barriers to work after October 2024 meant L&G reasonably relied on NHS recovery guidelines rather than the GP fit notes alone.

The Ombudsman's reasoning

The ombudsman found that while Mr M's illness was serious and his GP certified him unfit for work, the policy specifically requires incapacity for the full 26 week deferred period based on inability to perform the essential duties of his own occupation. The medical evidence showed Mr M was recovering steadily without complications by August 2024, and NHS guidelines suggested he could have started a phased return to work by October 2024. The GP fit notes did not provide objective evidence of functional incapacity beyond that point. L&G reasonably relied on average NHS recovery periods and the absence of evidence explaining how Mr M's condition prevented him from working after October 2024. Even considering both periods of absence together, the combined incapacity did not meet the required 26 weeks.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website