Unum Limited · DRN-6259077

The complaint Mr O is unhappy Unum Limited declined a claim on his income protection policy. What happened Mr O has a group income protection policy through his employer. The policy is underwritten by Unum and has a deferred period of 13 weeks. He became absent from work in December 2024 and submitted a claim. Unum declined cover because they said there wasn’t enough evidence to show Mr O met the definition of incapacity throughout the deferred period and beyond. Mr O provided further evidence to support his claim, but Unum maintained their position that there wasn’t enough to show he was incapacitated. Our investigator looked at everything and said Unum had fairly declined the claim. Mr O disagreed. In summary he said: • He didn’t think Unum had taken account of his detailed submissions at the start of August 2025, which explained the ongoing impact of his injuries and the functional limitations they caused him. • The evidence he’d provided explained that even relatively short periods of sitting or activity triggered significant flare-ups and required several days of recovery. So this shows he was unable to carry out the main duties of his role on a consistent basis. • Unum should have arranged an independent assessment before declining cover. The case 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 reasonable in the circumstances of this complaint. I may not respond to every point that has been raised, but I want to reassure both parties that I’ve considered everything that’s been submitted. The informal nature of this service enables me to do that so I can resolve complaints with minimal formality. The relevant rules and industry guidelines say an insurer has a responsibility to handle claims promptly and fairly and shouldn’t reject a claim unreasonably. The policy terms state a member is incapacitated if Unum 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

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• Not performing any occupation…..” To make a successful claim, Mr O must evidence he has been incapacitated for the full duration of the 13 week deferred period and beyond. I’ve carefully considered all the available evidence, this includes Mr O’s detailed personal log explaining how his symptoms impact his ability to sit for long periods and carry out activities. But I don’t think it was unreasonable for Unum to conclude there wasn’t enough objective medical evidence overall to show Mr O met the above definition throughout his deferred period and beyond. I’m not disputing Mr O’s symptoms or capabilities, it’s clear from his log that he is suffering. However, the bar is high for income protection claims. And the burden of proof is on Mr O as the claimant to show he has a valid claim under the policy. Unum needs to see objective medical evidence from a relevant professional to explain why Mr O’s symptoms prevent him from carrying out his occupation. So whilst Mr O’s personal recovery log was very detailed about the impact of his symptoms - it is self reported evidence. So I don’t think it was unfair for Unum to conclude this wasn’t enough to satisfy the definition of incapacity. I note Mr O made reference to a new diagnosis in his email of 1 August 2025. But I can’t see any medical evidence to support this change in his condition, so I don’t think it was unfair for this not to change Unum’s position. The orthopaedic surgeon reported no obvious abnormality in Mr O’s leg, full pain-free range of movement in each joint and confirmation that there wasn’t any restrictions in movement in his neck and left shoulder. He later also confirmed there was no abnormality found in Mr O’s MRI results at that time. I think it was fair for Unum to give weight to this expert opinion about Mr O’s reported restrictions, and decline cover on that basis. Mr O feels that Unum should have conducted an independent assessment of his condition before making a decision on cover, but as explained above, the onus was on Mr O as the claimant to prove he had a valid claim. And although he has provided detailed submissions about his symptoms and how they impact his role, I don’t think it was unreasonable for Unum to conclude this still wasn’t enough. I say that because although Mr O’s self-reported symptoms in isolation demonstrate he’s suffering with a functional incapacity, this isn’t supported by the objective medical evidence as highlighted by Unum. I therefore think it can reasonably rely on that argument to decline Mr O’s claim as he hasn’t shown he’s satisfied the incapacity term here” I’m sorry to hear Mr O is no longer employed due to his ill health. But for the reasons set out above, I think Unum fairly declined cover for his incapacity claim. I know this will be disappointing to Mr O, but there just isn’t enough objective medical evidence at the time of the decline to show he met the definition of incapacity. My final decision I don’t uphold this complaint for the reasons I’ve explained.

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Under the rules of the Financial Ombudsman Service, I’m required to ask Mr O to accept or reject my decision before 28 April 2026. Georgina Gill Ombudsman

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