DRN-6267358

The complaint Mrs H complains Aviva Life & Pensions UK Limited (Aviva) has declined the claim she made under a group income protection insurance policy. What happened The circumstances of this complaint will be well known to both parties and so I’ve summarised events. Mrs H is covered under a group income protection insurance policy through her employer. The policy is underwritten by Aviva. In March 2025 Mrs H became absent from work following ongoing eye pain and fatigue. A claim was submitted under the policy which was declined by Aviva. It said it didn’t think the medical evidence supported payment of a claim in line with the policy definition of incapacity. Mrs H raised a complaint. On 11 November 2025 Aviva issued Mrs H with a final response to her complaint. In relation to the eye condition Mrs H was suffering from it said there was no indication her returning to work would harm her eye, and it believed she could have continued working within the deferred period. In relation to Mrs H’s diagnosis of fibromyalgia, it said the activities reported in the medical evidence suggested a level of physical abilities that exceeded the requirements of a sedentary role. Mrs H contested this decision and Aviva wrote to Mrs H’s ophthalmologist to ask for further information. On 17 December 2025 Aviva issued Mrs H with a further final response to her complaint. It said whilst it couldn’t change its decision based on her ophthalmologist’s further report, it noted their recommendation that an occupational health specialist assess her ability to work. So, it said it would be happy to arrange an independent medical examination with an occupational health consultant to provide a consultant-level opinion on her fitness to work. Mrs H referred her complaint to this Service. Our Investigator looked into things but didn’t uphold the complaint. Mrs H didn’t agree with our Investigator. She provided a detailed response but in summary she said: • There is consistent medical evidence of her longstanding eye pain condition and functional incapacity to perform her own occupation. • She would like the ombudsman to give consideration to the realistic evidential standard for chronic pain and functional incapacity as applied to her own occupation. As an agreement couldn’t be reached the complaint has been passed to me to decide. What I’ve decided – and why I’ve considered all the available evidence and arguments to decide what’s fair and

-- 1 of 3 --

reasonable in the circumstances of this complaint. I want to acknowledge I’ve summarised Mrs H’s complaint in less detail than she’s presented it. I’ve not commented on every point she has raised. Instead, I’ve focused on what I consider to be the key points I need to think about. I mean no discourtesy by this, but it simply reflects the informal nature of this Service. I assure Mrs H and Aviva I’ve read and considered everything that’s been provided. The relevant rules and industry guidelines explain Aviva shouldn’t unreasonably reject a claim. The policy terms define incapacity as: ‘The member’s inability to perform on a full and part time basis the duties of their job role as a result of their illness or injury.’ The policy also includes a 26 week deferred period. This means Mrs H would need to be continuously incapacitated for 26 weeks before any benefit was due. The onus is on Mrs H to prove her claim. So, this means Mrs H needs to show, through medical evidence, that she was unable to perform her job role as a result of her illness throughout the deferred period and beyond. Aviva considered the evidence Mrs H provided in support of her claim, but it wasn’t persuaded she had shown she had met the policy definition of incapacity. I’ve considered the relevant medical evidence to decide whether I think Aviva acted fairly and reasonably when relying on this evidence to decline the claim. The medical evidence shows Mrs H has been diagnosed with fibromyalgia and suffers from symptoms related to this. However, it appears Mrs H isn’t suggesting it is these symptoms which are impacting her ability to carry out her job role. Rather it is the symptoms of her eye condition which are preventing her from carrying out her occupation. Therefore, I will focus my decision on this. But for completeness, I don’t think it was unreasonable for Aviva to conclude that Mrs H’s fibromyalgia wasn’t disabling to the extent of incapacity as the activities she reported she was able to carry out exceeded those necessary for her to carry out her sedentary occupation. I can see from the medical evidence Mrs H had seen an ophthalmologist and had a number of tests carried out in relation to the eye pain she had been experiencing. In July 2025 they wrote a letter in which they said: ‘An MRI brain and orbits scan was requested and I am pleased to report that this does not show any structural abnormalities or evidence of significant orbital inflammation. Minor small vessel disease was noted, in keeping with her age. Unfortunately, I am unable to find a clear explanation for Ms H’s symptoms, but our tests are reassuring in excluding serious underlying causes. This may implicate fibromyalgia or functional causes.’ Aviva wrote to Mrs H’s ophthalmologist asking questions about Mrs H’s symptoms and her ability to work. They responded to say without any objective abnormal findings they were reliant on Mrs H’s subjective experience of her symptoms. They said it was impossible for them to offer ‘objective evidence’ for the functional impact of Mrs H’s symptoms on her work beyond the consistent description of persistent symptoms which she had reported.

-- 2 of 3 --

Based on the medical evidence provided, I don’t think it was unreasonable for Aviva to conclude Mrs H hadn’t demonstrated she had met the policy definition of incapacity. In order to accept a claim, Mrs H would need to demonstrate that she was suffering symptoms of an injury or illness which were preventing her from working. And whilst Mrs H has been consistent around the symptoms she has been experiencing, I don’t think she has provided objective medical evidence that these symptoms are caused by an illness or injury and that this is preventing her from being able to carry out her occupation. I acknowledge Mrs H has said the medical evidence confirms her eye pain is chronic and reliably exacerbated by screen use. However, this is based on Mrs H’s reporting of the symptoms she is suffering rather than an objective medical report confirming an illness or injury is the likely cause of the symptoms. Similarly, whilst the occupational health reports say Mrs H is unable to carry out her job role, this is again based on Mrs H’s reporting. I’m aware symptoms of some conditions can’t be proven by objective medical tests and so are based on self-reporting. But I would usually expect this to be supported by the appropriate medical expert in order for a claim to be accepted on an income protection policy. In this instance the relevant medical expert has said they were unable to find a specific cause for Mrs H’s symptoms as all tests returned normal results. And so they could only rely on Mrs H’s reporting of her symptoms. And whilst there is a suggestion Mrs H’s symptoms may be linked to her diagnosis of fibromyalgia, I can’t see any medical evidence has been provided which confirms this to be the case. I know Mrs H has raised concerns about Aviva’s reasons for declining the claim, and I do think it’s initial decline could have been more detailed, particularly around its consideration of Mrs H’s eye condition given this was the main reason for her absence. However, I do think it provided a more detailed response following Mrs H raising her complaint, and its decision to decline the claim has ultimately been consistent in that it didn’t consider the medical evidence showed Mrs H met the policy definition of incapacity. So, I don’t require it to do anything further in relation to this. Taking all of this into consideration, I don’t think it was unreasonable Aviva didn’t accept Mrs H’s claim. But I think it’s offer to arrange for an independent medical examination is a reasonable one in the circumstances. This will allow it to gather further evidence around Mrs H’s medical conditions and appropriately re-consider her claim. If there are further issues following this, Mrs H can look to raise this as a separate complaint. My final decision For the reasons I’ve outlined above, I don’t uphold Mrs H’s complaint about Aviva Life & Pensions UK Limited. Under the rules of the Financial Ombudsman Service, I’m required to ask Mrs H to accept or reject my decision before 26 May 2026. Andrew Clarke Ombudsman

-- 3 of 3 --