DRN-6176755

The complaint Mrs H complains because Legal and General Assurance Society Limited (‘L&G’) hasn’t paid an income protection insurance claim. What happened Mrs H is insured under a group income protection insurance policy, provided by L&G. Unfortunately, Mrs H fell ill with chest pain and was investigated for cancer in multiple areas of her body. As a result, Mrs H was signed off sick from work in 2024 and made a claim with L&G under the income protection insurance policy. L&G said it didn’t think Mrs H had demonstrated that she met the threshold for a claim to be paid to her. However, L&G said it could consider a claim from a later date, following surgery Mrs H had in 2025. Unhappy, Mrs H complained to L&G before bringing the matter to the attention of our Service. One of our Investigators looked into what had happened and said she didn’t think L&G had acted unfairly or unreasonably in the circumstances. Mrs H didn’t agree with our Investigator’s opinion, so the complaint has now been referred to me to make a decision as the final stage in our process. 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. I’m sorry to hear about everything Mrs H has been through, and I have no doubt the experience has been very upsetting and stressful for her. I hope Mrs H is now in better health. I’ve read and carefully thought about all the detailed submissions both parties have made but I won’t be referring to every complaint point raised, and I’m not obliged to do so. Instead, reflecting our Service’s role as an informal alternative to the civil courts, I’ll only be addressing what I consider to be the key issues. Industry rules set out by the regulator say insurers must handle claims fairly and shouldn’t unreasonably reject a claim. I’ve taken these rules into account when making this final decision. In order for a benefit to be paid to Mrs H under this policy, Mrs H needs to demonstrate that she met the policy definition of ‘incapacity’ throughout, and beyond, the deferred period. This means Mrs H needs to show she was incapacitated by illness that prevented her from performing the essential duties of her occupation. I’m not a medical expert, so it’s not my role to reach my own conclusions about Mrs H’s medical conditions or to make assumptions about her abilities. Instead, I’ve weighed up the available medical evidence to decide whether, on the balance of probabilities, I think L&G

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acted unfairly and unreasonably when turning down Mrs H’s claim. It’s clear Mrs H has been unwell, and I don’t dispute she felt unable to work due to the circumstances she was in. However, overall, I haven’t seen any persuasive medical evidence which says Mrs H’s functioning was restricted to the extent that she was entirely unable to carry out her job due to her illnesses. The fact that Mrs H’s medical conditions necessitated multiple appointments at various hospitals doesn’t demonstrate that Mrs H met the policy definition of ‘incapacity’. Time off for appointments was a matter between Mrs H and her employer. And I wouldn’t generally consider that ‘Statements of Fitness for Work’ from a GP alone are persuasive evidence of incapacity. Such certificates are usually based on self-reported symptoms and contain limited information, and the threshold for issuing these isn’t the same as the criteria for an income protection insurance policy benefit to be paid. While I appreciate the time and effort Mrs H has taken in setting out detailed descriptions of how her illnesses affected her, this isn’t medical evidence and isn’t information upon which I could fairly ask L&G to pay this claim. It’s up to L&G to decide what evidence it needs to assess a claim. L&G did request and its Chief Medical Officer considered medical evidence from Mrs H’s GP (including the GP’s letter of 14 July 2025), and it also considered medical evidence which Mrs H sent to it directly. The information requests made by L&G were what I’d generally expect to see in a case like this. Mrs H sent our Service medical evidence which she says L&G hadn’t seen. I shared this with L&G, as required under the rules that govern the operation of our Service, but nothing I’ve seen changes my decision that Mrs H hasn’t demonstrated that she met the policy definition of ‘incapacity’. I understand there was a delay by L&G in requesting medical information but, based on the circumstances here including the timing of Mrs H’s investigations, I don’t think this delay was unreasonable overall. The fact that there were some factual errors in L&G’s correspondence with Mrs H, while unfortunate, doesn’t mean it has made a mistake by declining her claim. L&G offered to consider Mrs H’s claim from a later date (after her 2025 surgery). Mrs H was sent a consent form by a third party relating to this. Mrs H says she didn’t agree to being contacted by a third party, but I’ve seen a signed form where Mrs H allowed L&G permission to gather evidence relating to her claim via third parties. If Mrs H wants L&G to consider a claim from a later date, then she’ll need to either send L&G new medical evidence or cooperate with L&G’s consent request. Any subsequent dispute about the outcome of this claim would need to be the subject of a new complaint to L&G in the first instance before our Service would have the power to consider it. I’m sorry to disappoint Mrs H and I wish her well for the future, but I don’t think L&G acted unfairly or unreasonably by turning down her claim and I won’t be directing it to do anything further. My final decision My final decision is that I don’t uphold Mrs H’s complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mrs H to accept or reject my decision before 25 May 2026. Leah Nagle Ombudsman

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