Income Protection and Permanent Health Decision Reference 2023-0266

• Case Outcome: Substantially upheld
• Year: 2023
• Date: 29 November 2023
• Reference: 2023-0266
• Subject Matter: Income Protection and Permanent Health
• Finantial Sector: Insurance
• Conducts Complained Of: Claim handling delays or issues,Rejection of claim - non-disclosure & voiding

Decision Ref:

2023-0266

Sector:

Insurance

Product / Service:

Income Protection and Permanent Health

Conduct(s) complained of:

Claim handling delays or issues

Rejection of claim - non-disclosure & voiding

Outcome:

Substantially upheld

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

The Complainant became a voluntary member of a Group Income Protection Scheme on

30 March 2014. The Policyholder is the Trade Union that the Complainant is a member of.

The Policyholder engages a financial services firm to act as the Scheme Administrator. At

the time of the conduct complained of in 2015/2016, the Provider was the Insurer of the

Scheme, responsible for underwriting the applications for cover, and assessing claims.

This complaint concerns the Provider’s decision in March 2016 to decline the

Complainant’s income protection claim she submitted to it in September 2015, and to

cancel her cover from inception, due to the suggested non-disclosure of material facts

when she was applying for the cover.

The Complainant’s Case

The Complainant, a Senior [role redacted] says that she completed and signed a Salary

Protection Scheme Application Form, sent to the Provider on 18 February 2014, in which

she noted that she had previously undergone a hip arthroscopy in November 2013.

The Complainant says that the Provider then sent her an Arthritis, Muscle, Joint and Back

Disorders Underwriting Questionnaire, which she completed, signed and returned on 14

March 2014.

The Complainant says that the Provider then accepted her for membership of the Group

Income Protection Scheme with the following exclusion:

- 2 -

/Cont’d…

“No Income Protection benefit shall be payable if the circumstances giving rise to a

claim for benefit are directly or indirectly attributable to the left hip”.

The Complainant says that on 9 September 2015, she completed an Income Protection

Initial Claim Form to the Provider because she had been absent from work since 8 June

2015 because she had undergone surgery on her right hip and her recovery was slow,

which resulted in a period of extended sick leave, and she had exhausted her sick leave pay

entitlements with her employer.

The Complainant says that as part of its claim assessment, the Provider obtained medical

records from both her GP and her Consultant Orthopaedic Surgeon. The Complainant says

that the Scheme Administrator wrote to her on 7 March 2016, to advise that the Provider

was voiding her income protection cover from inception, because it had concluded that

she had failed to disclose during her application for the Group Income Protection Scheme

that she had previously attended her GP in June 2011 in relation to anxiety and

depression, and that she had also previously attended her Consultant Orthopaedic

Surgeon in July 2013 with a six to nine month history of pain in her left hip area and lower

back.

The Complainant says she was never previously diagnosed with, nor received treatment

for stress, anxiety or depression, nor was she previously diagnosed with or treated for a

back problem or back pain and, in this regard, she considers that the Provider has

misinterpreted her GP’s consultation notes and labelled her as having two medical

conditions that she did not, and does not, have.

The Complainant wrote to the Provider on 13 May 2016 to appeal its decision, as follows:

“I would like to address the interpretation of notes received from my GP in which

[the Provider] reached [its] decision to decline my claim.

In relation to Q4 (a) [“Have you ever suffered from or had treatment for…stress,

post-natal depression, anxiety, depression, nervous breakdown or mental

disorder?”]

[The Provider] pointed to a period in June 2011. I attended my GP after my

[relative] was diagnosed with a sudden serious illness. At the time I was caring for

him and my mother who had a longer-term illness. I was also working full-time and

had 3 young children. I was seen on that day by a locum who I didn’t know very well

at all. I wasn’t feeling well, I was very upset, exhausted and worried about my

family illnesses. I was given some time off work by the GP and asked to return in a

few days. I then saw my regular GP…and was already feeling better. She suggested

that it might be worth while talking to a counsellor, as it would be someone outside

my family to talk to.

I met a counselor on a few occasions. She felt I was very upset and suffering from

exhaustion and was taking on too much family responsibility and encouraged me to

get other family members to help, take some time off work and to learn to say “no”.