Not upheld: claim decline - insufficient medical evidence of incapacity complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Mr H claimed income protection benefits following a right hand and wrist injury sustained in January 2025, citing chronic pain and mental health conditions (anxiety, stress, autism, ADHD) as preventing him from working as a financial analyst. L&G declined the claim, arguing the medical evidence did not show functional impairment preventing return to work with adjustments. The ombudsman upheld L&G's decision, finding that while Mr H had documented injury and pain, the medical evidence fell short of demonstrating incapacity as defined by the suited occupation policy, and that occupational health recommendations for adaptive software and ergonomic support demonstrated Mr H could return to work in his role or alternative suitable occupations.

The Ombudsman's reasoning

The ombudsman found that while Mr H had a documented wrist injury with ongoing pain, the medical evidence did not adequately explain why his symptoms prevented him from working in his occupation or any suited occupation with reasonable adjustments. The occupational health specialist's recommendations for adaptive software, microbreaks, and ergonomic support demonstrated Mr H could return to work in some capacity. The ombudsman noted that policy diagnosis alone is insufficient; it must be supported by medical evidence explaining functional impairment. The ombudsman also found two of the three alternative roles recommended in the transferrable skills analysis to be suitable occupations Mr H could perform.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website