Not upheld: unfair claim decline / insufficient medical evidence complaint against Unum Limited

Decision detail

Summary

Mr B claimed income protection benefits under his employer's group policy with Unum following absence from work due to work-related stress in October 2023. Unum declined the first claim in February 2024, citing work-related stress as not a medical condition, and declined a second claim in July 2025 due to insufficient medical evidence of incapacity. Mr B argued that his diagnosed conditions (depression, anxiety, ADHD, autism) and PIP entitlement demonstrated his inability to work. The ombudsman upheld Unum's decisions, finding that whilst Mr B has medical conditions, the evidence does not objectively explain why he cannot perform his job duties, and that income protection claims require a higher threshold of medical evidence than PIP assessments.

The Ombudsman's reasoning

The ombudsman applied the policy definition of incapacity, which requires both a clear diagnosis of a medical condition and objective medical evidence explaining why that condition prevents the claimant from performing the material and substantial duties of their insured occupation. For the first claim, the evidence showed work-related stress, which is not a medical condition under the policy. For the second claim, whilst Mr B had diagnosed depression and anxiety, the medical evidence indicated stable management and contained no detailed explanation of why he could not work. The ombudsman rejected the argument that PIP entitlement should influence the assessment, as these are separate processes with different evidence thresholds. The ombudsman also rejected the suggestion that Unum should have arranged an independent medical examination at its expense, placing the burden on Mr B to provide sufficient medical evidence.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website