Payment Protection Decision Reference 2023-0166

• Case Outcome: Rejected
• Subject Matter: Payment Protection
• Reference: 2023-0166
• Date: 16 August 2023
• Finantial Sector: Insurance
• Conducts Complained Of: Rejection of claim - fit to return to work,Disagreement regarding Medical evidence submitted

Decision Ref:

2023-0166

Sector:

Insurance

Product / Service:

Payment Protection

Conduct(s) complained of:

Rejection of claim - fit to return to work

Disagreement regarding Medical evidence

submitted

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

This complaint relates to the refusal of an insurance claim made under an income

protection scheme.

The Complainant’s Case

The Complainant holds an insurance policy for income protection with the Provider, as

arranged through his employer. The Complainant submits that the Provider has refused to

approve his claim for income continuance for the defined period of August 2019 to May

2020. During this period, the Complainant’s only source of income was State disability

payments.

The Complainant states that:

“Medical evidence and advice available to [the employer and the Complainant]

clearly indicate that [the Complainant] was not fit for work and should have been

readmitted into the scheme.”

The Complainant has submitted reports from his consultant psychiatrist, his GP, and the

Chief Medical Officer (‘CMO’) of his employer, in support of his claim. The Complainant

states that he has been under the care of his consultant psychiatrist continuously since

2010.