Not upheld: claim declined — income protection insurance complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Mr D, a mechanic, claimed income protection insurance benefits after becoming unable to work due to back issues requiring spinal decompression surgery in June 2024. His employment ended on ill-health grounds in January 2025 and he submitted a claim under his employer's group income protection policy. Legal and General declined the claim, concluding Mr D had not met the policy's suited occupation definition of incapacity, which required him to demonstrate he was unable to perform any occupation suitable to his experience, training or education throughout a 41-week deferred period. The ombudsman upheld Legal and General's decision, finding that contemporaneous medical evidence from occupational health physicians post-surgery indicated Mr D retained functional capacity for a suited sedentary role with adjustments, and that Mr D had not met his burden of proving continuous incapacity throughout the entire deferred period.

The Ombudsman's reasoning

The ombudsman found that the medical evidence, particularly the contemporaneous occupational health reports following surgery, demonstrated Mr D retained functional capacity to perform a suited sedentary occupation during the deferred period. While acknowledging later deterioration shown in August 2025 evidence, the ombudsman noted this occurred after the deferred period had ended. The ombudsman accepted Legal and General's Chief Medical Officer's interpretation that the surgeon's recommendations reflected general degenerative back pain management guidance rather than absolute incapacity for sedentary work. The ombudsman found the transferrable skills analysis identified suitable alternative roles and concluded Mr D bore the burden of proving incapacity throughout the entire deferred period, which he had not done.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website