Not upheld: claim decline - insufficient medical evidence of incapacity complaint against UNUM LIMITED

Decision detail

Summary

Mr M claimed income protection insurance benefits in 2022 due to repetitive strain injury in his hand. Unum declined the claim, stating insufficient medical evidence of inability to use his hand. Mr M did not learn of the decline reason until years later, after his employment had ended. The ombudsman reviewed extensive medical evidence including GP certificates, physiotherapy records, and occupational physician reports. While these confirmed Mr M was unfit for his specific job, they suggested alternative work might be possible. The ombudsman upheld Unum's decision as the policy requires demonstration of inability to perform any reasonably fitted occupation, not just the original employment, and the available evidence did not meet this threshold.

The Ombudsman's reasoning

The ombudsman applied FOS rules requiring insurers to handle claims fairly and not unreasonably reject claims. The policy definition of incapacity requires inability to perform any gainful occupation for which reasonably fitted, not just the original employment. While medical evidence showed Mr M was unfit for his specific job role, the available medical evidence did not persuasively demonstrate total incapacity for any reasonably fitted alternative occupation. GP certificates alone are insufficient as they are based on self-reported symptoms and have a different threshold than the policy definition. The lack of recovery after eight months and absence of supporting evidence such as prescription medication, additional testing, and ongoing treatment plans supported Unum's position. Dr B's suggestion that redeployment to non-manual roles should be investigated indicated Mr M could potentially perform alternative work.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website