Not upheld: claim declined - failure to meet policy definition of incapacity complaint against Unum Limited

Decision detail

Summary

Mr F claimed income protection insurance benefits after becoming absent from work in April 2025 due to workplace stress, depression and anxiety. Unum declined the claim, stating there was insufficient evidence that Mr F was functionally unable to return to work due to a medical condition. Mr F complained, arguing that his condition was a genuine mental health illness preventing him from working and that Unum should have obtained specialist psychiatric assessment. The ombudsman found that the medical evidence consistently identified work-related stressors as the primary trigger for Mr F's symptoms rather than demonstrating an underlying medical condition meeting the policy's definition of incapacity. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman applied the policy definition of incapacity, which requires the policyholder to be unable to perform the material and substantial duties of their occupation due to illness or injury. The ombudsman noted that stress is not a recognised medical condition and that stress caused by workplace issues is different from being unable to perform one's occupation due to illness more generally. The ombudsman reviewed the medical evidence and found that the GP notes and occupational health reports consistently identified work as a significant stressor and trigger for Mr F's symptoms, rather than demonstrating an underlying medical condition that would prevent him from working regardless of workplace circumstances. The ombudsman concluded that receiving treatment alone does not demonstrate incapacity, and that Unum was not required to obtain specialist psychiatric input when the onus was on Mr F to provide evidence of incapacity.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website