Not upheld: unfair claim decline complaint against Legal and General Assurance Society Limited

Decision detail

Summary

Mrs W claimed income protection insurance benefits through her employer's group policy with L&G after becoming unable to work due to illness. L&G declined the claim on the basis that Mrs W did not meet the policy definition of incapacity, which requires inability to work in any suited occupation. L&G arranged an independent assessment identifying three alternative office-based roles Mrs W could undertake. The ombudsman upheld L&G's decision, finding that the medical evidence from the deferred period did not clearly show Mrs W could not work in these less demanding roles, and that the policy definition explicitly permits consideration of roles with lower pay and reduced seniority.

The Ombudsman's reasoning

The ombudsman applied the policy definition of incapacity which requires Mrs W to show she is unable to undertake all occupations suitable to her experience, training or education. The definition explicitly states that lower pay and reduced seniority do not make an occupation unsuitable. The medical evidence from the deferred period showed Mrs W was making progress and did not clearly explain why she could not work in the less demanding office-based roles identified by the independent assessment. The ombudsman found L&G's decision was based on reasonable consideration of the medical evidence and the skills assessment, and therefore was not unfair or unreasonable.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website