Zurich Assurance Ltd · DRN-6313932

The complaint Mr P has complained that Zurich Assurance Ltd declined his income protection insurance claim. What happened Mr P has a group income protection insurance policy via his employer, underwritten by Zurich. This would pay a benefit if Mr P was incapacitated – which means he would be unable to work due to illness or injury throughout the 26 week deferred (waiting) period and beyond. Mr P became absent from work and made a claim but Zurich declined it as it said Mr P didn’t meet the definition of incapacity. So he complained and unhappy with Zurich’s response, referred his complaint to the Financial Ombudsman Service. Our investigator looked into the complaint but didn’t think Zurich had unfairly declined the claim. Mr P disagreed and asked for an Ombudsman’s decision. He thinks the medical evidence has been ignored by both Zurich and the investigator. And so the case has been passed to me for a final 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. Having done so, I don’t think this complaint should be upheld. I’ll explain why. But firstly I’d like to say I am really sorry to hear of Mr P’s personal circumstances and the ill health of his young child. • The relevant rules and industry guidelines say an insurer should handle claims promptly and fairly and shouldn’t unreasonably reject a claim. • The background to this matter is well known to both parties. And I have carefully considered everything Mr P and Zurich have said even if I don’t explicitly address every point in my decision. I won’t repeat the facts here again. Instead I will focus on what I consider to be the crux of the complaint and what is key to my conclusions. • The starting point is the policy terms which define incapacity. • The definition is: “Incapacity or Incapacitated means an illness or injury that causes the Member to be unable to work and is applicable under this policy. The Incapacity definition that applies is in your policy schedule. The Member must be under the regular supervision and treatment of a Medical Practitioner…”

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• The relevant definition says: “The Member cannot perform the Material and Substantial Duties of their employment and they’re not doing any paid work.” • Mr P would have to show, through objective medical evidence, that he was unable to work due to illness or injury. • I have carefully reviewed the available medical evidence and what Mr P has said about his personal circumstances. In summary, Mr P’s young child was very unwell and in turn, he says this affected his mental health and his ability to work. • Initially, Mr P asked his employer whether he would be able to work from home due to his caring responsibilities. When he met with the occupational health (OH) adviser, they said he was unfit for work. Following this, he had regular OH reviews which concluded that he wouldn’t be fit for work until his child’s health matters settled. • Mr P has said that he was diagnosed with an adjustment disorder and it was explicitly stated that his symptoms resulted in him being medically unfit to work. He is unhappy that the investigator is effectively overriding the clinical judgment of a treating medical doctor in favour of a desk-based review by the insurer. Mr P said it was unreasonable for Zurich to dismiss fit notes and ignore a specialist referral for trauma focused therapy. He said it failed to seek further clarification from his GP or treating medical experts if the fit notes were insufficient. • Mr P has said a mental health collapse triggered by trauma is a medical condition and he has been under the regular supervision of a medical practitioner and has undergone specialised treatment. He therefore feels he has met all of the criteria of the policy. • I accept that Mr P was affected by the family trauma. But the policy only pays out where incapacity due to illness causes a member to be unable to work. Having symptoms or even a diagnosis of an illness by itself isn’t enough as many people are able to work with their illnesses. I would expect to see clear, objective medical evidence setting out what Mr P’s illness was, how that prevented him from carrying out the material and substantial duties of his role and that this lasted at least 26 weeks. • The medical evidence sets out a clear history of Mr P’s personal circumstances. There is no evidence that Mr P’s illness prevented him from caring for his family or causing other limitations as might be expected with an incapacitating mental health illness. Based on the symptoms given by Mr P’s GP and the OH adviser, they confirmed that Mr P needed to be off work until his child’s condition improved. • Mr P returned to work in December 2025 once his child’s planned surgery had taken place which meant Mr P’s mood improved and he was able to return to work. Zurich has said that this reinforces its view that Mr P’s absence was as a result of understandable stress during a difficult period rather than a significant medical illness. I don’t think Zurich’s view or conclusion is reasonable. Stress, as defined by the NHS, is a reaction to circumstances rather than an illness. • I have reviewed Zurich’s detailed assessments of the available medical evidence and I am satisfied it has fully considered and taken everything into account. Its chief medical officer’s conclusions were that Mr P could have worked from home at least on a part time basis and with support from his employer, for the following reasons: • Mr P had been unable to work due to stress, as outlined by the psychotherapist’s

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letter. • The OH adviser consistently referred to symptoms of an adjustment order but it was unclear whether the adviser was qualified to make this diagnosis. All assessments were done over the telephone and the reports focused primarily on Mr P’s child’s condition rather than Mr P’s own condition. • Mr P’s reactions were appropriate given the nature and severity of the stress he had been experiencing. Overall, having reviewed all the available medical evidence, I don’t think Zurich’s position was unreasonable. The onus is on Mr P to prove his claim. The medical evidence talks about his child’s condition and his caring responsibilities. There is no clear information about how Mr P’s illness would prevent him from working with reference to the material and substantial duties of his job. And so he hasn’t shown that he meets the definition of incapacity. I am sorry to disappoint Mr P as he will be unhappy with my decision. But I don’t think Zurich unfairly declined his claim so I won’t be asking it to do anything different. My final decision Your text here Under the rules of the Financial Ombudsman Service, I’m required to ask Mr P to accept or reject my decision before 21 May 2026. Shamaila Hussain Ombudsman

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