Payment Protection Decision Reference 2023-0161

• Case Outcome: Rejected
• Subject Matter: Payment Protection
• Reference: 2023-0161
• Date: 09 August 2023
• Finantial Sector: Insurance
• Conducts Complained Of: Disagreement regarding Medical evidence submitted ,Rejection of claim - fit to return to work

Decision Ref:

2023-0161

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 since 17 September

2012. The Scheme provides life, income protection and specified illness cover. The

Policyholder is a named Trade Union, and individual members of the Trade Union can

organise cover through the Scheme Administrator, which is a financial services broker

engaged by the Policyholder.

The Provider is the Insurer of this Scheme, responsible for underwriting the applications

for cover and for assessing claims. This complaint concerns the Provider’s decision to cease

payment of the Complainant’s income protection claim, which had been in payment since

15 February 2015, with effect from 1 July 2018.

The Complainant’s Case

The Complainant, a [Profession Redacted], completed an Income Protection Claim Form to

the Provider on 25 September 2014, wherein she detailed that she had been medically

certified as unfit for work since [date redacted] 2013 due to “[Injury Details redacted]”.

The Provider, following its assessment, admitted the Complainant’s income protection

claim with effect from 15 February 2015.

The Provider, following a later review of her claim, wrote to the Complainant on 13 March

2018 to advise that it had concluded from the medical evidence received throughout the

- 2 -

/Cont’d…

review, that she no longer satisfied the Group Income Protection Scheme policy definition

of disablement and that it was ceasing payment of her claim with effect from 1 July 2018.

The Complainant appealed this decision but following its appeal review, the Provider

wrote to the Complainant on 29 May 2019, to advise that based on the weight of the

medical evidence received, it remained its opinion that she no longer satisfied the policy

definition of disablement and was medically fit to carry out the duties of her normal

occupation and that it was standing over its decision to cease payments on her claim, a

position it has maintained since.

The Complainant sets out her complaint in the FSPO Complaint Form she completed, as

follows:

“[The Provider] stopped my payment even though I am still unwell. My problems –

pain, spasm, stiffness, cramping, twitching, limited movement of neck and right

upper limb, sleepiness etc. – are still present and its intensity varies from time to

time. I am forced to move from [County A] to [County B] due to my physical and

mental conditions, because I was unable to function [on] my own if my husband is

away for even one or two days. I am really worried and anxious about my future,

because I cannot see any hope anywhere”.

The Complainant submits in the FSPO Complaint Form that in order to resolve this matter,

she seeks for the Provider to reinstate payment of her income protection claim from 1 July

2018.

The Provider’s Case

The Provider says that in order for an income protection claim to be payable, a member of

the Group Income Protection Scheme must satisfy the following policy definition of

disablement:

1. Disablement

For the purpose of this Policy

(i) total disablement shall be deemed to exist where (a) the Insured

Person is unable to carry out the duties pertaining to his normal

occupation by reason of disablement arising from bodily injury

sustained or sickness or illness contracted and (b) the Insured Person

is not engaging on a full-time or part-time basis in any other

occupation (whether or not for profit or reward or remuneration,

including benefit in kind).

The Provider notes that the Complainant completed an Income Protection Claim Form on

25 September 2014 wherein she detailed the illness that prevented her from working

since [date redacted] 2013 as: