Not upheld: claim declined - insufficient medical evidence of incapacity complaint against Aviva Life & Pensions UK Limited

Decision detail

Summary

Mrs H claimed under a group income protection insurance policy underwritten by Aviva following her absence from work in March 2025 due to eye pain and fatigue. Aviva declined the claim, stating the medical evidence did not support that Mrs H met the policy definition of incapacity. Mrs H complained, but the ombudsman found that whilst she had consistently reported symptoms, she had not provided objective medical evidence that an illness or injury was causing these symptoms and preventing her from performing her occupation. The ophthalmologist confirmed all tests returned normal results and could only rely on Mrs H's subjective reporting. The ombudsman upheld Aviva's decision as reasonable and noted that Aviva's offer to arrange an independent medical examination was appropriate.

The Ombudsman's reasoning

The ombudsman found that whilst Mrs H had been consistent in reporting her symptoms, she had not provided objective medical evidence that an illness or injury was causing these symptoms and preventing her from performing her occupation. The relevant medical expert (ophthalmologist) had confirmed that all tests returned normal results and they could only rely on Mrs H's subjective reporting. Although some conditions cannot be proven by objective tests, the ombudsman would expect such claims to be supported by the appropriate medical expert. In this case, no specific cause for the symptoms had been identified, and no medical evidence confirmed a link to fibromyalgia. Therefore, Aviva's decision to decline the claim based on insufficient evidence of incapacity as defined by the policy was not unreasonable.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website