Assicurazioni Generali S.p.A UK Branch · DRN-6168269

The complaint Mr C complains that Assicurazioni Generali S.p.A UK Branch (‘Generali’) has stopped paying benefit for a claim he made under a group income protection insurance policy. To resolve his complaint, Mr C wants Generali to reinstate his benefit. What happened Mr C was a member of his employer’s group income protection insurance policy. Benefit of 67% of his salary was provided under the policy in the event that he was incapacitated due to illness or injury, for the duration of a 26-week deferred period and beyond. Mr C first went off sick from a longstanding full time (37.5 hours) training role in 2021 after being diagnosed with chronic fatigue syndrome (‘CFS’). Generali later accepted an income protection claim from Mr C in April 2022, backdating it to February 2022. The claim was revisited by Generali in 2024. It asked Mr C to undergo a two-day Chronic Pain Abilities Determination (‘CPAD’) assessment in September 2024 through a third party vocational rehabilitation business. Following this it was reported by the assessor that Mr C could attempt a graded return to work to 27.5 hours per week, across a 10-week period from January 2025. Mr C was initially able to engage with the graded return to work across incremental weekly working hours from 12 per week to 20 to 23 per week, but by May 2025 he reported that he couldn’t increase his working hours any further. In June 2025, Generali told Mr C’s employer that it could no longer continue to pay the income protection claim effective 1 July 2025. Though Mr C appealed and thereafter lodged a complaint, Generali would not change its view on ceasing the benefit. In October 2025, Generali issued a final response letter to the complaint in which it said that the findings of the CPAD assessment was the only objective medical evidence which specifically commented on Mr C’s ability to work. It didn’t feel that the medical evidence submitted by Mr C (from his consultant rheumatologist, Professor H) as part of his appeal evidenced that he remained incapacitated, as required by the policy terms. And so, it rejected the complaint. Mr C brought the complaint to this service. He noted that he had since been made redundant. He supplied a detailed supporting information document which set out the chronology of the complaint along with diary notes, He noted how his condition had since worsened due to anxiety, his reasons as to why the CPAD was flawed (due to failure to account for variability, the assessor’s qualifications and the failure to consider his cognitive impairments) and his request to undergo another CPAD. Our investigator said that Generali was entitled to review the claim periodically, and to rely on the CPAD assessment. He believed Generali had reached a fair conclusion that Mr C wasn’t totally incapacitated from performing his insured role. Mr C disagreed. He asked for his complaint to be referred to an ombudsman. He also

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submitted further written and verbal submissions with our investigator. I have read these in full. In summary, he said: • Talking was a substantial part of his job, and the assessor had set out that he had notable cognitive restrictions. • The graded return was very basic and did not cover many material aspects of his role. • He could only perform one aspect without restriction involving editing, but even this was undertaken with his eyes closed so as to limit visual impairment. • Just because he was managing his CFS doesn’t mean it has gone away. • He feels strongly that the CPAD was a flawed assessment, notably since he was managing his mental symptoms such as brain fog beforehand. • An ombudsman from this service issued a decision in very similar circumstances to his, instructing the insurer to reinstate proportionate income protection benefit. • During the graded return, he didn’t interact with anyone besides the insurer, human resources and his manager – so he could never have tested if he could actually work full time. • He merely went along with the graded increase to his working hours, partly due to external financial pressures. • He didn’t obtain any other medical evidence – such as seeing his GP – during the graded return to work because he would be wasting its time reporting an already known chronic illness. • Generali could have considered neurocognitive testing – but it didn’t do so. • He cannot understand how a complaint such as the decision he has referenced could succeed yet his could be refused when they rely on very similar facts. Generali didn’t have any other comments to add. The complaint has now been passed to me. 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 was sorry to learn of the difficulties that Mr C continues to face. I recognise that dealing with his claim is challenging given the impact of his condition, and I thank Mr C for the considerable effort he has gone to in providing submissions for this service to consider. In reaching my findings, I’ve set out the background to this complaint in less detail than the parties and I’ve done so using my own words. I’ve also focused on what I consider to be the central issues in the complaint. If there’s something I haven’t mentioned, it isn’t because I’ve ignored it - rather, it’s because I don’t need to comment on every argument in order to reach what I believe is the right outcome in the circumstances. Our rules allow me to take this approach; it reflects the informal nature of our service, as a free alternative to the courts. So, I haven’t set out the complete details of Mr C’s medical or employment circumstances, though I’ve carefully considered everything I’ve seen when reaching my decision. Regulatory rules require Generali to handle claims promptly and fairly and to not unreasonably reject a claim. Where an insurer terminates a claim which had been in payment, it would be for the insurer to show that the claimant no longer met the policy’s ‘definition of incapacity’, which for Mr C’s employer was set out as:

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“As a result of illness or injury, the Member is incapable of performing the Material and Substantial duties of their occupation, and they are not carrying out any other Work or occupation.” The policy also goes on to permit partial benefit to be payable at the sole discretion of Generali if an incapacitated member returns to their pre-incapacity occupation on a reduced basis with a reduced level of earnings or in a lower paid role. I do not believe the complaint should be upheld for the following reasons: • Based on the time that had passed, I don’t think it was unfair for Generali to appoint an external company to undertake a CPAD assessment with Mr C, and I can see he made concerted efforts across the two days to comply with the various aspects of the assessment. • Though Mr C has reflected on the experience of the assessor, I’ve seen no objective reason why the assessor wasn’t suitably qualified to undertake the CPAD assessment. The conclusions in the report were such that it was felt Mr C could return to work by utilising a graded return. And consideration was given to Mr C’s cognitive restrictions by way of a specific computerised neurocognitive assessment. • However, the CPAD did not evidence any severe cognitive issues. It noted minor cognitive issues that would not prevent a return to full time hours over the course of a phased return to work. • I accept that by May 2025 Mr C reported symptoms of a severity that prevented him from working in any capacity. However, this was based on his self-reporting of events, having tried to increase his hours and struggling beyond 20-23 hours before returning to being off sick. • The right approach is for Generali to apply the policy wording objectively against the medical evidence it has before it. And that wording is based upon incapacity such that a member cannot carry out the material and substantial duties of their insured occupation at all– that is a different test to being able to work at full capacity. • Generali says that Mr C demonstrated his ability to gradually increase hours over the course of several months by following a phased return to work schedule; this was sufficient evidence that the policy definition of incapacity was no longer being met. • Whilst I accept that the duties Mr C undertook may not have encompassed the range of duties he was undertaking before he first went off sick in 2021, Mr C was able to carry out some new tasks. However, Professor H explained in August 2025 that Mr C felt this was an unrealistic measure. He said: “Clearly there is a disconnect between the psychological and cognitive function tests that he has done where he scored very reasonably under non- stressful conditions and the result of his return to work which…ran through to May on a graded return. He has found that several aspects of his working ability such as his higher cognitive function, his stamina and energy levels and his physical exhaustion are all very much more stressed within an unpredictable workplace than they are within the predictability of cognitive assessment. He would like me to try to re-emphasise this and that the only way of really determining whether he is able to return to work in a fully effective way with no degree of presentism or forced absenteeism is to assess this in the real world. This does seem to have happened and ended

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with an exacerbation of his otherwise stable symptoms since May” . • Generali’s view on the evidence from Professor H is that it did not provide information about Mr C’s functional ability nor did it detail how he is physically or cognitively incapable of increasing his hours. I find that a reasonable statement. Professor H’s evidence was a reflection of Mr C’s feelings about the graded return to work, why it had been unsuccessful and sadly why his symptoms had flared as a consequence albeit he says this occurred since May 2025. • This was also borne out by the GP records from the time of the cessation of the graded return to work in May 2025. The GP noted Mr C’s trepidation about the failure to account for the cognitive nature of his insured occupation, but overall concluded on a fitness certificate that Mr C may be able to work. • My role isn’t to substitute my view for that of a business but instead, to determine if a business has acted fairly in all the circumstances of a complaint. Having looked carefully at the evidence and Mr C’s comments - I’m satisfied that Generali fairly reviewed the CPAD assessment along with Mr C’s appeal and reached a fair conclusion that he no longer met the policy definition of incapacity. And whilst Mr C doesn’t agree with the context of the CPAD (which set out that he could return to work in the face of some cognitive barriers), I’ve seen no reason why Generali couldn’t rely on it to ascertain Mr C’s functionality or place weight on it against the other medical evidence. Crucially, Mr C was able to return to work in some capacity – albeit he later went off sick because of an exacerbation of his symptoms. • I note in his comments following our investigator’s view that Mr C has referenced a decision issued by one of our ombudsmen with another insurer where a CPAD was undertaken for a claimant with CFS leading to neuropsychological recommendations that Mr C says Generali could have considered in the course of his claim. However, each complaint to this service is individual and based on its own set of specific facts. • That an ombudsman may have upheld a complaint with a similar background does not compel me to reach the same outcome in this complaint. Rather, I must look at this complaint; so that requires me to conclude whether I believe Generali has behaved fairly in all of the circumstances in terminating Mr C’s income protection benefit based on the medical evidence before it. In any event, in the facts of that complaint were materially different insofar as the insurer terminated the benefit before the claimant was able to complete the recommended graded return to work. • Overall, despite my natural sympathy with Mr C’s position, I think that Generali has provided enough evidence to show, on balance, that he no longer met the policy definition of incapacity after he resumed his graded return to work. And it reasonably concluded that no further medical evidence had been supplied which ought to outweigh the assessor’s evidence from the CPAD or from the ongoing support process undertaken during the graded return. It therefore reasonably terminated his incapacity claim as of July 2025. My final decision For the reasons set out, I do not uphold this complaint.

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

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