DRN-6192301

The complaint Mr R complains because Aviva Protection UK Limited hasn’t paid his claim under an income protection insurance policy. What happened Mr R is insured under a group income protection insurance policy. Mr R made a claim under the policy in 2024 because he was unable to work due to anxiety and depression. Aviva said it didn’t think Mr R had demonstrated that he met the threshold for a claim to be paid to him under the policy. Unhappy, Mr R complained to Aviva before bringing the matter to the attention of our Service. One of our Investigators looked into what had happened and said he didn’t think Aviva had acted unfairly or unreasonably in the circumstances. Mr R 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 Mr R has experienced. I have no doubt that having his claim declined will have been stressful and upsetting, and I hope he 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. Aviva has said this claim wasn’t notified to it within 90 days of the end of the deferred period, as required under the terms and conditions of the policy. However, Aviva has gone on to assess Mr R’s claim regardless and I think this is fair and reasonable in the circumstances. I don’t think it’s necessary for me to make any further findings about this point. In order for a benefit to be paid to Mr R under this policy, Mr R needs to demonstrate he met the policy definition of ‘incapacity’ throughout, and beyond, the deferred period. This means Mr R needs to show that he was unable to perform the material and substantial duties of his usual occupation as a result of illness. I’m not a medical expert, so it’s not my role to reach my own conclusions about Mr R’s medical condition or to make assumptions about his abilities. Instead, I’ve weighed up the available medical evidence to decide whether, on the balance of probabilities, I think Aviva

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acted unfairly and unreasonably when relying on this evidence to turn down Mr R’s claim. The fact that a different Aviva entity approved treatment for Mr R under a private medical insurance policy doesn’t have any bearing on whether I think Aviva acted unfairly or unreasonably with regard to the income protection insurance policy. These are two different policies, provided by different parts of the same company and different considerations apply to each policy. I understand Mr R didn’t feel able to work due to the circumstances he was in, and I don’t dispute he was unwell. However, overall, I haven’t seen any persuasive medical evidence which demonstrates that Mr R’s functioning was restricted to the extent that he was entirely unable to carry out his usual occupation due to illness. 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 include limited information. I’ve reviewed the letter Mr R has provided about the Employment and Support Allowance Support Group, but the threshold applied for this is not necessarily the same as the policy requirements for an income protection insurance claim to be paid. While the report from the Cognitive Behavioural Psychotherapist is information which I’d expect Aviva to take into account, I don’t think this is persuasive evidence that Mr R met the policy definition of ‘incapacity’ throughout and beyond the deferred period either. The report is somewhat limited in detail and, when taken together with Mr R’s medical records which I’ve been provided with, I don’t think Mr R has demonstrated that his claim is covered by the policy. The fact that Mr R’s employer is supportive of his claim doesn’t change this. I note the circumstances surrounding Aviva’s cancellation of a telephone assessment with Mr R. Based on the information available to it (which was that Mr R was travelling abroad), I don’t think this was unreasonable. However, even accepting that Aviva could have done more to facilitate rearranging the appointment, this doesn’t mean it would be fair to direct Aviva to accept this claim when I don’t think it’s otherwise covered. I’m sorry to disappoint Mr R and I wish him well for the future, but I don’t think Aviva acted unfairly or unreasonably by turning down his claim and I won’t be directing it to do anything further. My final decision My final decision is that I don’t uphold Mr R’s complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr R to accept or reject my decision before 26 May 2026. Leah Nagle Ombudsman

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