Not upheld: claim declined - insufficient evidence of incapacity complaint against Unum Limited

Decision detail

Summary

Mr V, a member of a group income protection insurance policy underwritten by Unum, became absent from work in April 2024 and submitted a claim. Unum declined the claim in December 2024, stating the evidence showed a stress reaction rather than acute mental illness, and maintained this decision in March 2025. Mr V provided additional medical evidence including GP notes, a GP letter, an occupational health report, and a consultant psychiatrist report, all confirming diagnoses of anxiety and depression but suggesting his symptoms were triggered by work-related stressors. The ombudsman found that whilst Mr V had a valid diagnosis, the medical evidence did not demonstrate he was unable to perform the material and substantial duties of his job role as required by the policy definition of incapacity, and that Unum acted fairly and reasonably in declining the claim.

The Ombudsman's reasoning

The ombudsman found that whilst Mr V had a diagnosis of anxiety and depression, a diagnosis alone does not meet the policy definition of incapacity. The policy requires demonstration that symptoms prevented Mr V from carrying out the material and substantial duties of his job role. The medical evidence provided did not detail the specific symptoms Mr V experienced during the deferred period or explain why these prevented him from working. The evidence suggested his absence was related to workplace stressors which, if removed, would likely allow him to return to work. The ombudsman noted that incapacity due to stress is generally not considered to meet the policy definition as individuals can usually return to work once stressors are resolved. The assessment must consider whether Mr V could perform his job role generally, not whether he could perform it at his specific workplace with specific stressors present.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website