DRN-6250234

The complaint Mrs M is unhappy that Unum Limited have declined a claim she made on her employer’s group income protection policy. What happened Mrs M has been absent from work – she gave birth prematurely which led to complications for her baby. This was a traumatic experience which has impacted on Mrs M’s long term mental health. She claimed on her employer’s group income protection policy as she was unable to return to work as planned. Unum declined the claim as they didn’t think the policy definition of incapacity was met. Mrs M appealed and complained to Unum but they maintained their decision was fair and in line with the policy terms. Unhappy, Mrs M complained to the Financial Ombudsman Service. Our investigator looked into what happened and didn’t uphold the complaint. She thought Unum had acted fairly based on the available medical evidence and the policy terms. Mrs M didn’t agree and asked an ombudsman to review her complaint. She remained unhappy that Unum hadn’t engaged with the specialists in her treating team and said Unum didn’t make it clear what information needed to be provided to demonstrate incapacity. She also highlighted that her diagnosis of Post Traumatic Stress Disorder (PTSD) directly impacted on her ability to do her job as she was unable to leave her child. And she explained that she felt questions about her circumstances hadn’t been asked. So, the complaint was referred to me to make a 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. The relevant rules and industry guidelines say that Unum have a responsibility to handle claims promptly and fairly. And they shouldn’t reject a claim unreasonably. At the outset I acknowledge that I’ve summarised this complaint in far less detail than Mrs M has, and in my own words. I won’t respond to every single point made. No discourtesy is intended by this. Instead, I’ve focussed on what I think are the key issues here. The rules that govern our 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 individual point to be able to fulfil my statutory remit. I also want to acknowledge the circumstances which led to Mrs M’s claim. It’s clear from what she’s said, and the information provided in support of her claim, that she has been

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through an incredibly difficult time. I have a lot of empathy for what she’s said about her circumstances, and I appreciate that this has been a very distressing and upsetting experience for her. The policy terms and conditions The policy terms and conditions say: A member is incapacitated if we are satisfied that they are: • Unable, by reason of their illness or injury, to perform the material and substantial duties of the insured occupation, and are • Not performing any occupation If the member is required by the terms governing the employment relationship to hold a licence or certificate which is issued only when the member meets required medical standards, we must also be satisfied that they are unable, by reason of their illness or injury, to perform the material and substantial duties of any gainful occupation with any employer for which they are reasonably fitted by reason of training, education or experience. The term "licence" does not include a licence to drive ordinary cars, vans or motorcycles. Insured occupation means: ‘the trade, profession or general role that the member was actively undertaking for you immediately prior to incapacity’. Have Unum fairly declined the claim? I’m very sorry to disappoint Mrs M but I’m persuaded Unum has fairly declined the claim. I say that because: • I’m satisfied Unum reasonably concluded, based on the medical evidence, that the main barrier to Mrs M returning to work was being unable to entrust the care of her son to others. • The medical evidence demonstrates that Mrs M had a mental health condition which impacted on her ability to leave her son. The medical evidence provided does say that Mrs M wasn’t well enough to work. But I think Unum reasonably concluded that the policy definition of incapacity wasn’t met as the medical evidence doesn’t persuasively demonstrate that Mrs M was unable to carry out the material and substantial duties of her occupation. Mrs M has said that being unable to leave her son means she can’t work. However, I think Unum reasonably concluded that’s not within the scope of the cover offered by the policy. • Mrs M felt that Unum ought to have contacted the specialists involved in her care and asked specific questions of them. There’s no specific requirement for them to do so. And, based on the evidence that was presented to Unum, I don’t think they acted unreasonably by not seeking specific information from the specialists. Furthermore, when information was provided to Unum from the specialists this was considered in detail by Unum.

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• It’s for Mrs M to demonstrate she has a valid claim. It’s not for Unum to show that she doesn’t. Therefore, I wouldn’t expect Unum to explain to Mrs M what evidence is required to demonstrate a valid claim. Their role is to assess the evidence presented to decide if there’s a valid claim under the policy. • I’m satisfied Mrs M was provided with a reasonable level of service by Unum. That includes during phone calls with their staff. And, I’m satisfied that there were detailed and comprehensive reviews of the claim, with input from Unum’s medical team where appropriate. My final decision I’m not upholding this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mrs M to accept or reject my decision before 21 May 2026. Anna Wilshaw Ombudsman

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