Not upheld: unreasonable claim rejection complaint against Chesnara Life (UK) Limited

Decision detail

Summary

Mr G, covered under an employer group income protection scheme with a 26-week deferred period, stopped work on 20 February 2025 citing ADHD with anxiety and depression and claimed income protection benefits. Chesnara rejected the claim, finding insufficient evidence that Mr G met the policy definition of incapacity throughout the deferred period. The ombudsman upheld Chesnara's decision, finding that while Mr G had genuine mental health difficulties including ADHD diagnosed in October 2024, the medical evidence showed no significant deterioration before stopping work, his GP found minimal evidence of significant psychiatric illness, work-related stressors appeared to be a primary contributing factor, and occupational health suggested he could return to work once workplace issues were resolved.

The Ombudsman's reasoning

The ombudsman applied FCA rules requiring insurers not to unreasonably reject claims and examined whether Mr G met the policy definition of incapacity (unable to perform material and substantial duties of his occupation due to illness or injury) throughout the 26-week deferred period. The ombudsman found that while Mr G had ADHD and experienced mental health difficulties, the medical evidence did not support significant deterioration before he stopped work, his GP found minimal evidence of significant psychiatric illness in April 2025, work-related stressors appeared to be a primary factor, and occupational health suggested he could return to work once workplace issues were resolved. The ombudsman noted that Mr G's symptoms appeared to improve by July 2025 and that the medical evidence lacked detailed descriptions of functional limitations specific to his job role.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website