DRN-6063722

The complaint Ms O is unhappy that Vitality Life Limited (‘Vitality’) declined a claim under her personal protection plan – which included income protection insurance (‘the policy’) – even though she’d been signed off by her GP as not being able to work. What happened The details of this complaint are well known to both parties, so I won’t repeat them again here. I’ll focus on giving the reasons for my decision. What I’ve decided – and why I’ve considered all the available evidence and arguments to decide what’s fair and reasonable in the circumstances of this complaint. That includes all points made by Ms O along with all the other evidence. I won’t respond to each of these. I hope she understands that no discourtesy is intended by this. Instead, I’ve focussed on what I think are the key issues here. The rules that govern the Financial Ombudsman Service allow me to do this as we are an informal dispute resolution service. If there’s something I’ve not mentioned, it isn’t because I’ve overlooked it. I haven’t. I’m satisfied I don’t need to comment on every point to fulfil my statutory remit. In considering what’s fair and reasonable in all the circumstances of the case, I’ve taken into account all relevant law and regulations, regulator’s rules, guidance and standards, codes of practice and good industry practice at the relevant time. That includes Vitality’s regulatory obligation to handle insurance claims promptly and fairly – and to not unreasonably decline a claim. I have a lot of empathy for Ms O’s situation. I also know Vitality’s decision to decline the claim will have financially impacted her. However, for reasons set out below, I’m satisfied Vitality has fairly and reasonably declined her claim. The relevant policy terms The policy provides a monthly benefit (after the initial deferred period of one month) if Ms O became “ill, injured or disabled” and the definition of incapacity is met. Relevant to this complaint, ‘incapacity’ means: Illness or injury makes you unable to perform the material and substantial duties of your own occupation. These are duties that are normally needed to do your own occupation and that cannot reasonably be omitted or modified by you or your employer. The decision to decline the claim

-- 1 of 3 --

It’s for Ms O to establish a claim under the policy, including that she was incapacitated as defined by the policy terms throughout the deferred period of one month, and beyond. It’s not for Vitality to show that she didn’t meet the definition. • Having considered Ms O’s medical records from the deferred period, I’m satisfied that Vitality has fairly concluded that there’s limited objective medical evidence to support that Ms O met that definition. I accept that Ms O was certified as being unfit to work by her GP throughout the deferred period (and beyond) with depression. However, the policy has a specific definition which needs to be met. So, whilst relevant, I don’t think being signed off work is determinative. • The GP notes from around the time of first certifying Ms O as unfit to work (beginning of November 2024) reflect that she’d recently returned to work after having a baby and was “struggling”. She felt she returned to work too soon, was feeling anxious and emotional, on edge, had low mood and energy and wasn’t sleeping well. Her PHQ-9 and GAD-7 scores showed moderate to severe depression and anxiety. • However, Ms O’s symptoms are largely self-reported. The medical evidence gives limited objective medical insight into how illness impaired her functionality or impacted her ability to perform the material and substantial duties of her occupation throughout the deferred period. • The GP notes also reflect that Ms O was initially diagnosed with stress symptoms and signed off work until the end of December 2024. However, the next day, and at her request (based on advice she said she’d received from her employer), the diagnosis was changed to depression and the sick note extended to the end of January 2025. It’s reflected that a return-to-work date of the start of February 2025 had been agreed with her employer. There’s nothing else to suggest that Ms O had any further interaction with medical professionals during this time or had any treatment, such as medication or therapy. • I note that Ms O says Vitality failed to progress a referral for therapy during the deferred period, which may have provided further evidence to support her claim that she was incapacitated and would’ve also supported her recovery. However, I think it’s fair and reasonable for Vitality to assess the claim based on the available medical evidence rather than what the medical evidence may have shown if she’d had therapy. Further, if Ms O needed support (including therapy) to treat her symptoms, I think it’s reasonable to assume that she would’ve chased Vitality again about the referral when she heard nothing further from it and/or visited her GP to discuss. I’ve seen no compelling evidence that she did that shortly after the end of the deferred period. • I’ve also taken into account Vitality’s Chief Medical Officer’s initial opinion that the high GAD score and PHQ scores around the time of first being signed off sick were indicative of a difficulty returning to work due to symptoms of moderate depression and severe anxiety. And that these symptoms were likely to affect Ms O’s ability to concentrate and focus at work. However, when the issue was referred back to the Chief Medical Officer, it’s reflected the advice was: “I take on board that [Ms O] was not treated and what is potentially swaying my opinion now is that the sicknote was extended the next day…without any further follow-up or review. We therefore lack objective evidence to support her inability to work beyond the [deferred period]”. • I’ve also taken into account reference in Vitality’s communications that Ms O was a number of weeks post-partum. And it is “understandable that she had minimal sleep and have felt stressed being back at work”. However, I don’t think this comment was

-- 2 of 3 --

unreasonable in the circumstances of this case or prejudiced the ultimate decision to decline the claim because of insufficient objective medical evidence to establish that Ms O met the policy definition of incapacity. • I’ve taken into account Ms O’s other concerns, including what she says about Vitality not requesting further information from her GP. I don’t think Vitality was required to do so in the circumstances of this case. I think it was fair for it to rely on the GP records it had which were contemporaneous evidence from the deferred period. • Ms O has provided a GP letter, and a letter from a private medical clinic, but I don’t think that adds much to what is already set out in the medical evidence from the time. The way the claim was handled Vitality accepts that there were errors when handling Ms O’s claim and when supporting her, including delaying accessing information from Ms O’s GP and unnecessarily delaying the outcome of the claim. Vitality also told Ms O that her claim had been approved towards the end of July 2025 and that it was currently calculating the benefit amount. Within a week later, it said the claim had been declined. I can understand that this would’ve been very upsetting and confusing for Ms O. She was also put to the unnecessary inconvenience of chasing Vitality to know what was going on during the claims’ process. Vitality has apologised, said that feedback has been given and offered £500 compensation which I understand has been paid to Ms O. I’m satisfied this is fair and reasonable to put things right here and fairly reflects the impact on Ms O. If the errors hadn’t occurred, Ms O would’ve still been disappointed by the ultimate decision to decline her claim. But she would’ve received this outcome quicker, without having to spend time chasing and her expectations that the claim would be paid wouldn’t have been unfairly raised. My final decision Vitality Life Limited doesn’t need to do anything more to put things right. I don’t uphold this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Ms O to accept or reject my decision before 25 May 2026. David Curtis-Johnson Ombudsman

-- 3 of 3 --