Not upheld: claim denial — incapacity definition not met complaint against Unum Limited

Decision detail

Summary

Mrs M claimed on her employer's group income protection policy after giving birth prematurely, which led to complications for her baby and resulted in PTSD that prevented her from returning to work. Unum declined the claim, concluding the policy definition of incapacity was not met. Mrs M appealed, arguing Unum should have engaged with her treating specialists and made clearer what information was needed. The ombudsman upheld Unum's decision, finding that while Mrs M had a genuine mental health condition, the policy definition of incapacity requires inability to perform the material and substantial duties of her occupation, not inability to arrange childcare. The ombudsman concluded Unum was not required to proactively contact specialists and that it is the claimant's responsibility to demonstrate a valid claim.

The Ombudsman's reasoning

The ombudsman concluded that Unum reasonably interpreted the policy definition of incapacity based on the medical evidence presented. While Mrs M had a genuine mental health condition (PTSD) that prevented her from leaving her son, the policy definition requires inability to perform the material and substantial duties of her occupation, not inability to arrange childcare. The ombudsman found that Unum was not required to proactively contact specialists or explain what evidence would be needed to support a claim, as it is the claimant's responsibility to demonstrate a valid claim. The ombudsman was satisfied Unum provided reasonable service and conducted detailed reviews of the claim.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website