Payment Protection Decision Reference 2020-0362

• Jurisdiction: Ireland
• Case Outcome: Rejected
• Reference: 2020-0362
• Year: 2020
• Date: 16 October 2020
• Subject Matter: Payment Protection
• Conducts Complained Of: Disagreement regarding Medical evidence submitted ,Rejection of claim - fit to return to work
• Finantial Sector: Insurance

Decision Ref:

2020-0362

Sector:

Insurance

Product / Service:

Payment Protection

Conduct(s) complained of:

Disagreement regarding Medical evidence

submitted

Rejection of claim - fit to return to work

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

The Complainant is a member of a Group Income Protection Scheme. Her Employer is the

policyholder and the Provider the insurer, responsible for the underwriting of applications

for cover and assessing claims.

The Complainant’s Case

The Complainant, who works for her Employer from home as a [specified job title], has been

absent from work since [date redacted] 2017. She completed an income protection claim

form to the Provider on 25 July 2017 when she detailed the illnesses that prevented her

from working, as follows:

“Describe in detail your illness/condition

Hiatus Hernia

- Stomach pain, burning sensation

- Need to eat regularly

- Feeling nauseous

Gallbladder Dysfunction

- Pain in abdomen area regardless of type of food taken, constant pain, no relief

from pain medication

- Sharp pain in back shoulder blade

- Feeling very tired

- Loss of appetite

- 2 -

/Cont’d…

Sporadic Hemiplegic Migraine

- Visual impairment

- Motor function impairment

- Loss of feeling in hands

- Speech disturbance

- Memory loss/confusion

- Feeling tired for several weeks/months after attack. Last attack Sunday 2nd of July

2017.

Stress

- Anxiety

- Loss of appetite

- Dizzy/faint

- Memory issues

- Problems sleeping

How does your condition prevent you from working?

Gallbladder + hernia

Pain in abdomen and back

Feeling like vomiting

Sometimes the pain is very bad. I need to lie down. Symptoms of all ailments increase

with stressful activity i.e. loss of appetite / not sleeping.

Pain is worse when sitting – pain is [alleviated] while lying down.

Pain is very sharp and it is very hard to concentrate when having an attack.

What work related activities does your current condition prevent you from

performing?

Hemiplegic Migraine

- Loss of memory / speech / visual loss / motor function loss

- Concentration (resolving technical issues within a time limit)

- Sitting for long periods of time

- With Hemiplegic Migraine (unable to perform any work duties due to the severity

of the attack)

Stress / depression

- Feeling very anxious daily”.

Following its claim assessment, the Provider was satisfied that the Complainant met the

Group Income Protection Scheme policy definition of disability for a period and it made a

one-off claim payment in October 2017 to cover the period from 10 September 2017 (the

expiry of the 26 week deferred period) to 30 November 2017.

The Complainant appealed this decision and on consideration of new evidence, the Provider

fully reinstated the claim in May 2018 and backdated it with a retrospective payment from

1 December 2017.

- 3 -

/Cont’d…

This claim remained in payment until 31 March 2019, from which date, following a claim

review, the Provider concluded that the Complainant no longer satisfied the policy definition

of disability and was fit to work.

The Complainant appealed this decision and following its review, the Provider made a

further claim payment for the period 27 June 2019 to 31 August 2019 to help support a

phased return to work for the Complainant.

The Complainant is dissatisfied that the Provider ceased payment of her income protection

claim, in circumstances where she and her treating health professionals consider that she

remains unfit to work.

In this regard, in the Complaint Form she completed on 17 September 2019, the

Complainant sets out her complaint, as follows:

“In March 2017, I became very ill. I had been for many tests over the previous years.

I had been unwell for over a decade. In March 2017, I found myself no longer able to

control my symptoms. I went out on sick leave from work. Soon afterwards on [date]

2017, I lost my husband suddenly. My symptoms, namely, [Chronic Fatigue

Syndrome], [Irritable Bowel Syndrome] and chronic pain became a lot worse. I was

later diagnosed with Severe Fibromyalgia by [Consultant Rheumatologist Dr A.].

I was referred to [Dr A.] by a pain specialist…after pain treatments failed to relieve

me. As well as having Fibromyalgia, I was also diagnosed with depression by

[Consultant Psychiatrist Dr C.]. Given I had just lost my husband at the age of

[thirties], I was now suffering with depressive moods and also [Post-Traumatic

Stress].

On advice from my former manager at [my Employer], I completed a long term illness

application and sent it to [the Provider]. [The Provider] declined my claim based on

a consultation with a psychiatrist. I appealed this, and had a further consultation with

[Dr D.], a Consultant Rheumatologist through [the Provider]. [The Provider] then

accepted my claim and back paid me. Over the year, I continued to have further

symptoms. I became suicidal in May 2018 and sought help from [Service]. I was still

attending my psychiatrist. She later changed my medication by increasing my

antidepressants.

As the end of [2018] approached, [the Provider] again assessed me for my claim, this

time declining.

I am making this complaint as for the following reasons:

I am still suffering with Severe Fibromyalgia. I suffer greatly with Chronic Fatigue

Syndrome. Also, when immobile for long periods of time, 60 mins +, I become very

sore especially in my back, upper back, shoulder blades and also neck. My job requires

me to sit on a chair for the majority of my shift i.e. 8+ hours.