Not upheld: Travel / life insurance claim disputes complaint against Aviva Life & Pensions UK Limited

Decision detail

Summary

Mrs C claimed income protection benefits following a fractured shoulder sustained in November 2023, submitting her claim in May 2024. Aviva declined the claim, stating insufficient medical evidence demonstrated total incapacity throughout the 26-week deferred period. Mrs C subsequently developed depression, which she attributed to her injury, but Aviva determined this was caused by workplace stress (an excluded cause). The ombudsman upheld Aviva's decision, finding the physical injury had resolved sufficiently for return to work within four months and that workplace stress, not the injury, was the primary barrier to Mrs C's return. The ombudsman concluded there was insufficient objective medical evidence to support Mrs C's claim for depression-related incapacity.

The Ombudsman's reasoning

The ombudsman applied ICOBS rules requiring Aviva to assess claims promptly and fairly without unreasonably rejecting them. The policy requires proof of total incapacity to perform job duties as a result of illness or injury. The ombudsman found: (1) the physical shoulder injury had resolved sufficiently to permit return to work within four months, supported by medical evidence; (2) Mrs C herself confirmed in June 2024 that her shoulder was not preventing return to work; (3) the primary barrier to return was workplace stress, which is explicitly excluded from the policy; (4) there was no objective medical testimony explaining why Mrs C could not perform her sedentary role due to depression symptoms; and (5) it is Mrs C's burden to prove a valid claim, not Aviva's burden to disprove it. The ombudsman considered evidence within the 26-week deferred period reasonable and noted that later reports from December 2024 onwards fell outside this window and were therefore not required.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website