Not upheld: claim declined - failure to establish incapacity under policy definition complaint against Unum Limited

Decision detail

Summary

Miss D claimed income protection insurance benefits through her ex-employer's group policy after being certified unfit to work due to chronic fatigue syndrome, depression, anxiety and abdominal pain. Unum declined the claim, finding that Miss D had not established she met the policy's specific definition of incapacity throughout the 26-week deferred period. The ombudsman upheld Unum's decision, finding that whilst Miss D was signed off work and received state welfare benefits, the medical evidence lacked sufficient objective detail about how her illnesses impaired her ability to perform the material and substantial duties of her insured occupation throughout the entire deferred period. The ombudsman also rejected Miss D's concerns about conflict of interest, medical records requests, and lack of policy information, finding Unum had acted fairly and reasonably throughout.

The Ombudsman's reasoning

The ombudsman found that whilst Miss D was certified unfit to work by her GP and received state welfare benefits, the policy has a specific definition of incapacity that must be met. The medical evidence did not provide sufficient objective insight into how Miss D's illnesses impaired her functionality or ability to perform the material and substantial duties of her insured occupation throughout the entire 26-week deferred period. The evidence was largely self-reported. Being signed off work and receiving welfare benefits are not determinative factors under the policy's specific definition. Unum fairly and reasonably considered the available medical evidence and concluded the claim had not been established. The ombudsman also found Unum did not breach its obligations regarding conflict of interest, medical records requests, or provision of policy terms.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website