Not upheld: Travel / life insurance claim disputes complaint against Royal London Mutual Insurance Society, Limited (trading as Scottish Provident)

Decision detail

Summary

Ms T claimed Total Permanent Disability (TPD) benefit on a mortgage protection insurance policy after being diagnosed with Long Covid and unable to work. Royal London obtained medical evidence including GP records and occupational health reports, and appointed an Independent Medical Examiner who concluded Ms T was fit to perform her usual duties on a part-time basis. Royal London rejected the claim as the medical evidence did not demonstrate that Ms T's condition met the policy definition of TPD, which requires permanent inability to perform her own occupation. The ombudsman upheld Royal London's decision, finding it fair and reasonable to rely on the medical evidence from two occupational health specialists, despite Ms T's current unfitness to work and acceptance of her income protection claim by a different insurer.

The Ombudsman's reasoning

The ombudsman applied the plain and ordinary meaning of 'permanent' in the policy definition to mean indefinite or forever. The ombudsman found it was Ms T's responsibility to provide sufficient evidence that her condition met the TPD definition. While acknowledging Ms T's current unfitness to work, the ombudsman concluded that the medical evidence from two occupational health specialists did not establish that Ms T's condition would permanently prevent her from performing her own occupation. The OH physician noted possible longer-term unfitness but did not make a finding of permanent inability, and the IME explicitly concluded Ms T was fit to perform her usual duties on a full or part-time basis. The ombudsman declined to weigh medical evidence as that is not the ombudsman's role, but rather assessed whether Royal London fairly relied on the evidence to reach its decision.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website