Upheld: unfair claim rejection / failure to arrange independent medical examination complaint against Legal and General Assurance Society Limited
Financial Ombudsman decision DRN-6396276 of 2026-06-02T00:00:00+00:00. unfair claim rejection / failure to arrange independent medical examination complaint against Legal and General Assurance Society Limited. Outcome: Upheld.
Decision detail
| Reference | DRN-6396276 |
|---|---|
| Decision date | 2026-06-02T00:00:00+00:00 |
| Firm | Legal and General Assurance Society Limited |
| Product | income protection insurance |
| Claim type | unfair claim rejection / failure to arrange independent medical examination |
| Outcome | Upheld |
| Remedy | L&G must: (1) pay Mr M's claim from the end of the deferred period until the date his cover under the policy ended; (2) pay simple interest at time-weighted average Bank of England base rate plus one percentage point on each claim payment from the date each payment was due until settlement; (3) pay Mr M £500 compensation for distress and inconvenience experienced. Claim payments to be made to Mr M's former employer as policyholder, though L&G may choose to pay directly to Mr M. |
Summary
Mr M claimed income protection insurance benefits after being signed off work due to Prolonged Grief Disorder and PTSD following his child's death. L&G declined the claim, stating Mr M did not meet the policy definition of 'incapacity'. Mr M provided two detailed GP letters and three vocational specialist reports indicating he was unable to perform any employment, but L&G's Chief Medical Officer disagreed. The ombudsman upheld the complaint, finding that L&G acted unfairly by not arranging an independent medical examination when faced with conflicting medical evidence. The ombudsman determined Mr M likely met the policy definition of 'incapacity' and directed L&G to pay the claim from the end of the deferred period until cover ended, plus interest and £500 compensation for distress and inconvenience.
The Ombudsman's reasoning
The ombudsman found that while the GP letters were dated after the deferred period and lacked specific functional analysis, they constituted credible medical evidence from Mr M's treating doctors that he was unable to perform any employment. When combined with the three VCS reports, this evidence supported a conclusion that Mr M likely met the policy definition of 'incapacity'. The ombudsman found the treating GP's opinion more persuasive than L&G's CMO opinion and determined that L&G should have arranged an independent medical examination when faced with conflicting medical evidence. On balance, the ombudsman was satisfied that Mr M had demonstrated he more likely than not met the policy definition of 'incapacity'. The ombudsman rejected Mr M's argument that L&G's actions caused his redundancy, finding that redundancy would likely have occurred regardless due to the variables in the redundancy scheme.
How this compares
| Group | Decisions | Uphold rate |
|---|---|---|
| Legal and General Assurance Society Limited, all decisions | 1,103 | 18% |
Source
Read the original decision on the Financial Ombudsman Service website