Not upheld: claim decline - income protection insurance complaint against Exeter Friendly Society Limited

Decision detail

Summary

Miss M claimed income protection insurance benefits after becoming unable to work due to pain, weakness and reduced function in her right hand and wrist, initially attributed to carpal tunnel syndrome and later to repetitive strain injury. Exeter Friendly declined the claim based on a functional capacity examination report which concluded Miss M's actual functional abilities were greater than her self-reported symptoms suggested. Miss M disputed this, arguing the FCE should not outweigh other evidence including her continued work absence and updated diagnosis of tendonitis. The ombudsman found Exeter Friendly acted fairly in relying on the FCE report from a medically trained physiotherapist and concluded Miss M had not demonstrated she was totally unable to work in her own occupation as required by the policy terms.

The Ombudsman's reasoning

The ombudsman found that the policy required Miss M to prove she was totally unable to work in her own occupation due to illness or injury. The functional capacity examination report, completed by a medically trained physiotherapist who assessed Miss M in person, concluded that her demonstrated functional abilities did not represent her true capabilities and that her self-reported symptoms could not represent barriers to returning to work. The ombudsman considered this report persuasive evidence and found it was not unreasonable for Exeter Friendly to rely on it. Although Miss M continued to be signed off work and had further investigations pending, the ombudsman found this did not demonstrate she had met the policy requirements, and noted that no further diagnosis or information had been provided at the time of Exeter Friendly's final response.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website