Not upheld: claim declined — insufficient medical evidence complaint against Scottish Friendly Assurance Society Limited

Decision detail

Summary

Mr W claimed income protection insurance benefits from Scottish Friendly after reporting inability to work since July 2025 due to neck and stomach pains. Scottish Friendly declined the claim in December 2025, stating insufficient objective medical evidence of incapacity. The ombudsman upheld Scottish Friendly's decision, finding that the available medical evidence (GP notes and questionnaire) did not support that Mr W was unable to perform the material and substantial duties of his occupation as a barber. The GP evidence indicated normal function for walking, sitting and standing, and the restrictions noted (avoiding heavy lifting and bending) were not material to his role. Additionally, there was a discrepancy between Mr W's claim of a July 2025 hospital visit and the absence of any such visit in comprehensive GP records.

The Ombudsman's reasoning

The ombudsman applied the policy definition of incapacity, which requires the claimant to be unable to perform the material and substantial duties of their own occupation. The burden of proof rests on Mr W to demonstrate through medical evidence that he met this definition throughout the deferred period and beyond. The available medical evidence showed Mr W had normal function for walking, sitting and standing, and could perform roles not requiring heavy lifting or bending. Since a barber's occupation does not primarily require heavy lifting or bending, the medical evidence did not support that Mr W was unable to carry out his occupation. The discrepancy between Mr W's claim of a July 2025 hospital visit and the absence of any such visit in GP records dating back to 2000 further undermined the claim.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website