Not upheld: claim declined — failure to meet policy incapacity definition complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Miss G claimed on a group income protection insurance policy whilst off sick from work, but Legal and General declined the claim. Miss G appealed and the complaint was referred to the FOS. The ombudsman found that whilst Miss G was certified as unfit to work by her GP and received state welfare benefits, the policy has a specific incapacity definition requiring that illness prevented her from performing the essential duties of her occupation. The medical evidence during the deferred period was limited and largely self-reported, and contemporary evidence consistently identified workplace issues as the cause of absence. Although more recent medical evidence confirmed unfitness to work from December 2024 onwards, it acknowledged that workplace interactions and legal disputes were negatively impacting recovery. The ombudsman concluded that the main barrier to working during the deferred period was workplace issues, which falls within the policy exclusion, and therefore upheld Legal and General's decision to decline the claim.

The Ombudsman's reasoning

The ombudsman concluded that Miss G failed to establish she met the policy's specific incapacity definition during the deferred period. Whilst Miss G was certified as unfit to work and received state welfare benefits, these are not determinative under the policy terms. The medical evidence provided limited objective insight into how illness impaired her functionality during the entire deferred period, with symptoms largely self-reported. Critically, contemporary evidence consistently identified workplace issues as the cause of absence, not illness. More recent medical evidence, whilst confirming unfitness to work from December 2024 onwards, acknowledged that ongoing legal disputes and workplace interactions were negatively impacting recovery, and that mental health deterioration was linked to work-related issues. The ombudsman found the main barrier to working during the deferred period was workplace issues rather than illness, which falls within the policy exclusion for workplace issues.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website