Partially upheld: claim decline — insufficient medical evidence of incapacity; administrative error in deferred period calculation complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Mr H claimed on a group income protection insurance policy while off sick with complex medical symptoms including jaw, head, neck and stomach pain. Legal and General declined the claim, and Mr H appealed. The ombudsman found that although Mr H was certified unfit to work by his GP and had occupational health reports supporting this, the medical evidence was insufficient to establish he met the policy's specific incapacity definition, which requires objective evidence that illness prevented him from performing essential job duties. However, the complaint was partially upheld because Legal and General had incorrectly calculated the deferred period by including a period when Mr H was working on reduced hours, causing confusion and distress. The ombudsman awarded £300 compensation for this administrative error while upholding the claim decline as fair.

The Ombudsman's reasoning

The ombudsman found that Legal and General fairly declined the claim because Mr H failed to establish that he met the specific incapacity definition in the policy terms throughout the deferred period. Although Mr H was certified unfit to work by his GP and had occupational health reports supporting this, the ombudsman found these were based on self-reporting rather than objective medical evidence. The medical investigation results were broadly within normal limits, and there was insufficient objective medical evidence to support that Mr H's symptoms prevented him from performing the essential duties of his role. However, the ombudsman upheld the complaint to the extent that Legal and General's error in calculating the deferred period caused confusion and distress, warranting £300 compensation.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website