Not upheld: claim declined - insufficient evidence of incapacity complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Miss A claimed on an income protection policy after becoming absent from work due to mental health issues, gastro-intestinal symptoms and dental problems. Legal and General declined the claim, concluding the medical evidence did not demonstrate she met the policy's 'own occupation' definition of incapacity. Miss A complained, arguing her phased return to work was a medical trial and that her treating specialists' evidence was not given sufficient weight. The ombudsman upheld Legal and General's decision, finding that expert medical assessments reasonably concluded the policy definition of incapacity was not met, that workplace issues rather than clinical incapacity appeared to be the primary cause of absence, and that evidence from treating specialists did not provide meaningful insight into why Miss A could not work.

The Ombudsman's reasoning

The ombudsman concluded that Legal and General reasonably declined the claim because the overall medical evidence did not demonstrate that Miss A was unable to perform the essential duties of her occupation under the 'own occupation' definition. The ombudsman found that the consultant occupational physician and Chief Medical Officer's assessments were reasonable, that evidence from treating specialists did not provide meaningful insight into why Miss A could not work, and that workplace issues are not evidence of incapacity under the policy. The ombudsman also found it reasonable for Legal and General to consider the fertility procedure as inconsistent with the severity of symptoms reported.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website