Income Protection and Permanent Health Decision Reference 2022-0314

• Case Outcome: Partially upheld
• Subject Matter: Income Protection and Permanent Health
• Reference: 2022-0314
• Date: 08 September 2022
• Finantial Sector: Insurance
• Conducts Complained Of: Dissatisfaction with customer service ,Claim handling delays or issues, Disagreement regarding Medical evidence submitted

Decision Ref:

2022-0314

Sector:

Insurance

Product / Service:

Income Protection and Permanent Health

Conduct(s) complained of:

Dissatisfaction with customer service

Claim handling delays or issues

Disagreement regarding Medical evidence

submitted

Outcome:

Partially upheld

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

The Complainant is a voluntary member of a Group Salary Protection Scheme since 1

November 1986. The Scheme provides life, income protection and specified illness cover.

The Grantees of this Scheme are a named Trade Union, the individual members of which

can organise cover through the Scheme Administrator, a financial services broker engaged

by the Grantees. The Provider is the Insurer of this Scheme, responsible for underwriting the

applications for cover and assessing claims. This complaint concerns the Provider’s

administration of the Complainant’s income protection claim.

The Complainant’s Case

The Complainant, a primary school teacher, completed an Income Protection Claim

Notification Form sent to the Provider on 25 February 2015. She advised that she had been

medically certified as unfit for work since 11 June 2014. The Complainant says she had fallen

severely ill due to numerous conditions that included post-surgery complications and that

she suffered from nerve damage, resulting in her having difficulty using one of her feet,

thereafter.

As part of its assessment of her claim, the Provider arranged for the Complainant to have a

tele-interview with a nurse on 13 March 2015. In her letter to this Office dated 9 January

2019, the Complainant says that the nurse asked her questions in relation to her smoking

and alcohol consumption and in that regard, she submits that:

- 2 -

/Cont’d…

“Smoking and drinking alcohol have no bearing on my situation - severe sepsis and

dropped foot and post-operative hernia – but I was questioned about both non-

existent habits unnecessarily in my opinion”.

Following its assessment, the Provider wrote to the Scheme Administrator on 15 May 2015

to confirm that it was admitting the Complainant’s income protection claim, and the first

claim payment was made to her bank account on 1 June 2015.

The Complainant says that her employer granted her early retirement on ill-health grounds

from 16 March 2016 and that she will never be able to work as a teacher again.

As part of a later review of her income protection claim, the Provider arranged for the

Complainant to attend for a medical examination with a Specialist in Occupational Health

on 15 August 2017. In her ensuing Report dated 24 August 2017, this Specialist concluded

that the Complainant was fit to return to work.

The Complainant says the Specialist’s Report contained many omissions and inaccuracies

and she set these out in detail in her letter of 16 January 2018 to the Provider’s Medical

Officer, who forwarded her letter to the Specialist. The Complainant is displeased with the

Specialist’s response of 14 February 2018 and in that regard, in her letter to this Office dated

18 December 2019, the Complainant submits that:

“… [the Specialist’s] response to my “errors and omissions” letter clearly indicates

that her opinion was that because I could read and critically appraise her report and

prepare a detailed response therefore I should be able to resume teaching duties”.

In addition, in her letter to this Office dated 9 January 2019, the Complainant says that when

concluding the examination on 15 August 2017, the Specialist said to her:

“…and I quote verbatim, “Now [Complainant name redacted], is there anything else

you want to tell me because you are [age redacted] and [the Provider] will want to

get you off [its] books”.

As part of its claim review, the Provider also asked the Complainant to complete a two-day

Chronic Pain Abilities Determination at her home on 27 and 29 November 2017. The

Complainant says she did not want to undergo the CPAD Assessment without first having

sight of the Specialist’s Report from August 2017. The Complainant says that the Scheme

Administrator, on her behalf, emailed the Provider on 1 November 2017 asking for it to send

a copy of the Specialist’s Report to her GP but as the Provider failed to do so at the time, the

Administrator had to contact the Provider on 15 November and again on 21 November

2017. The Complainant says that this delay meant she was not able to review the contents

of the Specialist’s Report in advance of the CPAD Assessment and this resulted in her

cancelling that appointment.