Unum Limited · DRN-6168167

The complaint Mr S has complained about the way Unum Limited handled and declined his claim for Total Permanent Disability (TPD). What happened Mr S had a group critical illness insurance policy with TPD benefit through his employer. He became unwell and was absent from work so he made a claim. Unum declined the claim. Mr S appealed and complained. Unhappy with Unum’s response, he referred his complaint to the Financial Ombudsman Service. Our investigator looked into the complaint but didn’t think Unum had unfairly declined the claim. Mr S disagreed and asked for an Ombudsman’s decision. 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. Firstly, I'd like to say I am really sorry to hear of Mr S’ ill health and the circumstances which led to this claim. 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 has been set out in quite some detail by the investigator. And I have carefully considered everything both parties 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 and conditions which make up the contract of insurance. The relevant policy definition for TPD which applies to Mr S is as follows: “Total permanent Disability – unable to do your own occupation ever again Loss of physical or mental ability through an illness or injury to the extent that the member is unable to do the material and substantial duties of their own occupation ever again. The material and substantial duties are those that are normally required for, and/or form a significant and integral part of, the performance of the person’s own occupation that cannot reasonably be omitted or modified.

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Own occupation means your trade, profession or type of work you do for profit or pay. It is not a specific job with any particular employer and is irrespective of location and availability. The relevant specialists must reasonably expect that the disability will last throughout life with no prospect of improvement, irrespective of when the cover ends or the member expects to retire. For the above definition, disabilities for which the relevant specialists cannot give a clear prognosis are not covered.” Mr S’ employer is the policy holder and he was covered by the policy as an employee. The policy also confirms when cover continues during absence and when it will stop as follows: “Cover continues during absence due to illness or injury…for up to 3 years…Cover is provided as long as: The member remains employed by you”. “Your cover will stop…if you no longer work for your employer…” I note Mr S is unhappy that Unum referred to his employment end date in its decline letter. But the policy clearly confirms that cover only continues during absence as long as Mr S remains employed and cover stops if he is no longer employed. However, Unum reviewed medical evidence after his employment end date to determine whether Mr S met the definition of TPD whilst he was employed. This means he would need to provide evidence from a specialist which confirmed that whilst Mr S was still employed – up until the date his employment ended, his disability would last throughout life with no prospect of improvement. I haven’t seen any evidence that Mr S’ specialist has provided confirmation that Mr S’ disability would last throughout life with no prospect of improvement, at the time he was still employed and still covered under the terms of the policy. Mr S did receive a diagnosis and was absent due to his illness whilst he was employed. But this alone, and without the confirmation from a specialist that he met the full criteria for a TPD claim, isn’t sufficient. So I don’t think Mr S has shown he met the policy terms. Mr S’ GP has provided a letter which says his conditions are: “…chronic, permanent and unlikely to improve. His symptoms prevent him returning back to his job…to perform his duties and no work place adjustments would make any difference that would enable him to return back to his job in the future.” This evidence provided after the end date of Mr S’ employment does not provide confirmation from a specialist that his disability has no (my emphasis) prospect of improvement. The evidence does not suggest that Mr S’ GP is a specialist in his condition. And it does not confirm that this prognosis applied at the time Mr S was still employed and covered. Mr S has referred to “irrespective of when the cover ends” to mean that he can receive a prognosis any time after his employment end date but I disagree. The term and paragraph should be read as a whole and in context. The full term says: “The relevant specialists must reasonably expect that the disability will last throughout life with no prospect of improvement, irrespective of when the cover ends or the member expects to retire.” This means that the specialist must confirm the disability will last throughout life with no

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prospect of improvement even if the cover ended (for example) a year later. It doesn’t say the specialist can provide the confirmation at any point after cover has ended. The “irrespective of when cover ends” applies to the prognosis and not the date the prognosis is provided as suggested by Mr S. Mr S’ response to the investigator’s view and evidence provided during a service complaint I can confirm I have reviewed all the submissions Mr S has sent into the investigator, many of which are lengthy and duplicated, as well as the information provided in response to the view and the service complaint which has been dealt with separately by a manager. I have summarised Mr S’ concerns. I will not respond to all of his detailed points as I am expected to deal with matters as quickly as possible and with minimum formality. I have also taken all the relevant rules and principles into consideration including the Consumer Duty. I will focus on what is key to my conclusions. • The view is based on a misinterpretation of the master policy and ignores Unum’s conduct. I have set out above the relevant terms applicable to Mr S’ claim. I don’t think the policy has been misinterpreted by the investigator. It seems that Mr S has misinterpreted the terms as I have set out above. • Unum accepted a premium payment after his employment ended and so the dismissal date is waived. Our investigator has already explained that as the policyholder is Mr S’ previous employer, the employer would be responsible for collecting and passing premiums to Unum. I don’t think this waives the dismissal date and the policy terms are clear about when cover ends. The premium payment is something Mr S would need to take up with his previous employer. • The complaint should be upheld on the admitted August event date. I don’t agree that the event date is the August date. Mr S was diagnosed with his conditions in August but this isn’t enough on its own to meet the policy criteria for TPD. Being diagnosed with a serious illness doesn’t necessarily always result in the criteria being met as treatment plans can be arranged and some people do get better or can cope. • Unum applied a higher threshold by incorrectly referring to the incorrect definition for TPD (Activities of Daily Living and the child definition). Unum set out the full wording of the TPD section in its final response letter but it clearly confirmed on more than one occasion and in the final response letter that the criteria being used was “unable to do your own occupation ever again”. So I don’t agree that Unum applied a higher threshold. • The complete medical evidence wasn’t considered and the relevant evidence was dismissed. The GP has provided the prognosis required even though this was issued after his employment ended. I can confirm I have reviewed all of the medical evidence provided and referred to by Mr S including the letter from the GP but I don’t agree that a specialist has confirmed that Mr S’ “disability will last throughout life with no prospect of improvement.” The GP has said Mr S is unlikely to improve. This is not the same as having no prospect of improvement. A specialist would need to confirm that Mr S’ disability had no prospect of improvement to meet the

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criteria for a successful TPD claim. I am really sorry to disappoint Mr S but I don’t think Unum unfairly declined his claim. My final decision For the reasons set out above, I don’t uphold this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr S to accept or reject my decision before 3 April 2026. Shamaila Hussain Ombudsman

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