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

Decision detail

Summary

Ms S claimed under a group income protection insurance policy provided by Unum after being signed off work due to stress in July 2024. Unum declined the claim in November 2024, stating the evidence did not show Ms S met the policy definition of incapacity. Ms S provided additional evidence including a later diagnosis of ADHD and ASD, but Unum maintained its decision. The ombudsman found that whilst Ms S suffered from depression, anxiety, and neurodevelopmental conditions, the medical evidence did not demonstrate she was unable to perform her job role during the 13-week deferred period. The ombudsman upheld Unum's decision as reasonable and did not require an independent medical examination, as the later occupational health assessment was provided too late to evidence incapacity during the relevant period.

The Ombudsman's reasoning

The ombudsman found that whilst Ms S had received treatment and been prescribed medication for depression and anxiety, and was later diagnosed with ADHD and ASD, the medical evidence did not demonstrate she was unable to carry out her job role during the deferred period. The ombudsman noted that neurodiversity does not necessarily preclude an individual from performing their occupation, particularly when they have previously been able to do so. The occupational health report from January 2026 was considered too late (18 months after absence began) to provide information about Ms S's symptoms during the relevant deferred period. The GP letter from March 2026 expressed Ms S's own feeling of inability to work rather than the GP's professional opinion on her functional capacity. The ombudsman concluded Unum fairly considered the available medical evidence and reasonably concluded Ms S had not met the policy definition of incapacity.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website