Not upheld: incapacity claim denial / assessment of claim against policy definition complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Ms D claimed incapacity benefit under her employer's group income protection insurance policy following a work-related back injury in August 2024 and subsequent bowel issues. L&G obtained comprehensive medical evidence and sought its Chief Medical Officer's opinion, concluding that Ms D had not met the policy definition of incapacity. The ombudsman reviewed all available medical evidence, including occupational health assessments, GP records, and specialist clinic notes, and found that while Ms D had genuine symptoms, the evidence did not compellingly demonstrate incapacity in line with the policy terms. The ombudsman upheld L&G's decision, finding it fair and reasonable to rely on the Chief Medical Officer's expert opinion that there was insufficient evidence of debilitating illness throughout the deferred period.

The Ombudsman's reasoning

The ombudsman applied the policy definition of incapacity, which requires the insured member to be incapacitated by illness or injury preventing them from performing the essential duties of their occupation. The ombudsman found that while Ms D had genuine symptoms and her GP issued fit notes, the medical evidence did not compellingly demonstrate incapacity in line with the policy terms. The ombudsman placed significant weight on the Chief Medical Officer's expert opinion, which identified: (1) the initial soft-tissue injury would typically recover within a few weeks; (2) insufficient evidence of debilitating gastrointestinal illness (tests showed only mild gastritis); (3) lack of documented physical or neurological examination findings supporting disabling restriction; and (4) no major radiculopathy or red flag pathology. The ombudsman noted that the emergency department expected recovery in 2 weeks and occupational health initially supported phased return to work, suggesting the condition was not as severe as later claimed. The ombudsman declined to substitute their own clinical judgment for expert medical opinion.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website