Not upheld: claim declined - failure to meet policy definitions complaint against Unum Limited

Decision detail

Summary

Ms G claimed on her employer's group critical illness policy with Unum following a stroke in 2023 and subsequent profound hearing loss. Unum declined both the deafness claim (hearing loss below the 95 decibel policy threshold) and the stroke claim (medical records indicated the stroke was caused by head trauma from a fall, which is excluded from cover). Ms G disputed this, contending the stroke caused her to fall rather than the reverse. The ombudsman found Unum's decision fair and reasonable, noting that contemporaneous medical notes documented the fall and head injury preceding the seizure, and that Unum's analysis of the treatment received supported their conclusion. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman concluded that Unum's decision was fair and reasonable based on the available medical evidence. For the deafness claim, the hearing loss in Ms G's better ear was objectively measured at less than 95 decibels, falling short of the policy definition threshold. For the stroke claim, the contemporaneous medical notes from the day of the incident clearly documented a fall with head trauma preceding the seizure, and Unum reasonably concluded the stroke was caused by the traumatic head injury rather than the reverse. The ombudsman found the contemporaneous notes more persuasive than later notes and noted that Unum's analysis of the treatment received (absence of aneurysm-specific interventions and stroke team referral) supported their conclusion. The ombudsman also clarified that it is not the FOS's role to make medical judgments but rather to assess whether the firm's conclusion was fair and reasonable based on available evidence.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website