Not upheld: unfair claim decline complaint against Zurich Assurance Ltd

Decision detail

Summary

Mr P claimed income protection insurance benefits after becoming unable to work, attributing his absence to stress and mental health issues triggered by his young child's serious illness. Zurich declined the claim on the basis that Mr P did not meet the policy definition of incapacity. The ombudsman reviewed the medical evidence, including occupational health reports, fit notes, and a diagnosis of adjustment disorder, but found that the evidence primarily documented Mr P's child's condition and caring responsibilities rather than clear evidence that Mr P's illness prevented him from performing his job duties. The ombudsman upheld Zurich's position that Mr P had not provided sufficient objective medical evidence to meet the policy's definition of incapacity and did not uphold the complaint.

The Ombudsman's reasoning

The ombudsman applied the policy definition of incapacity, which requires that the member be unable to perform the material and substantial duties of their employment due to illness or injury, supported by objective medical evidence. While accepting that Mr P was affected by family trauma and had a diagnosis of adjustment disorder, the ombudsman found that the medical evidence primarily documented Mr P's child's condition and caring responsibilities rather than clear evidence of how Mr P's illness prevented him from working. The fact that Mr P returned to work once his child's surgery took place suggested his absence was due to stress (a reaction to circumstances) rather than a significant medical illness. The ombudsman was satisfied that Zurich's position was reasonable and that Mr P had not met the burden of proving his claim.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website