Legal and General Assurance Society Limited · DRN-6245803

The complaint Ms B complains Legal and General Assurance Society Limited (Legal and General) has declined the claim she made under an income protection insurance policy. What happened The circumstances of this complaint will be well known to both parties and so I’ve summarised events. Ms B was covered under a group income protection insurance policy through her employer. The policy was provided by Legal and General. In May 2024 Ms B became absent from work and a claim was subsequently submitted under the policy. Legal and General considered Ms B’s claim but in November 2024 it declined it. It said the medical evidence received confirmed her absence was stress-related and its medical officer considered it would have been reasonable for Ms B to have returned to work in summer 2024, completing a phased return to work. Ms B appealed Legal and General’s claim decision, but it didn’t change its position so Ms B raised a complaint. On 5 September 2025 Legal and General issued Ms B with a final response to her complaint. It said there was a lack of objective medical evidence to suggest clinical conditions causing functional restrictions to a level which would prevent Ms B from achieving a return to work throughout the deferred period. Ms B referred her complaint to this Service. Our investigator looked into things and upheld Ms B’s complaint. He said he didn’t think Legal and General had given sufficient weight to the medical evidence provided which said Ms B was suffering from a mental health condition preventing her from working. He said he thought Legal and General should re-consider the claim, requesting evidence directly from Ms B’s GP, therapist and psychiatrist and pay Ms B £150 compensation. Legal and General didn’t agree with our Investigator. It provided a detailed response but in summary it said it didn’t think Ms B had met the policy definition of incapacity during the deferred period. But it said it was willing to obtain further evidence from Ms B’s therapist and psychiatrist. I issued a provisional decision about this complaint and I said: ‘I want to acknowledge I’ve summarised Ms B’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 Ms B and Legal and General I’ve read and considered everything that’s been provided. The relevant rules and industry guidelines explain Legal and General should handle claims fairly and shouldn’t unreasonably reject a claim.

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The policy terms explain Legal and General will pay benefit if a member meets the policy definition of incapacity. Incapacity is defined in the policy as: ‘Means the insured member is incapacitated by illness or injury that prevents him from performing the essential duties of his occupation immediately before the start of the deferred period. The insured member’s capacity to perform the essential duties of his own occupation will be determined whether or not that occupation remains available to him.’ The policy also includes a 26 week deferred period. This means Ms B would need to demonstrate she was continuously incapacitated for 26 weeks before any benefit would be paid. The onus is on Ms B to provide information in support of her claim. So, this means Ms B would need to show, through medical evidence, she met the policy definition of incapacity throughout the deferred period and beyond. I wouldn’t generally consider that someone suffering from stress, work-related or otherwise, would meet the policy definition of incapacity as an individual could usually return to work once these issues were resolved. Legal and General considered the evidence Ms B provided in support of her claim, but it wasn’t persuaded Ms B had shown she met the policy definition of incapacity. I’ve considered the relevant available medical evidence to decide whether I think Legal and General acted fairly and reasonably when relying on this evidence to decline the claim. Whilst I don’t intend to list every piece of evidence, such as every GP appointment, I’ve summarised what I consider to be the key medical evidence here: • In May 2024 Ms B requested an extension of a sick note from her GP as she was struggling with the prospect of returning to work. This was provided and the reason for absence was recorded as a ‘stress related problem’. • In June 2024 Ms B’s psychotherapist wrote a letter to say Ms B was presenting with severe depression and associated severe anxiety. They noted that work was a particular stressor but that Ms B felt her difficulties were broader and more longstanding than just work related. • At the beginning of July 2024 Ms B requested a referral for autism spectrum disorder (ASD). • In the same month Ms B spoke with a vocational clinical specialist who wrote in their report that they didn’t consider Ms B fit to return to work at that time. Ms B also spoke with an occupational health advisor who said they didn’t consider Ms B fit to return to work but she would benefit from a phased return when she was. • In August 2024 Ms B spoke with a vocational clinical specialist who recorded that Ms B was hopeful of a return to work in the coming weeks, and that they believed the return to work plan was appropriate. • In October 2024 Ms B spoke with an occupational health advisor who reported that Ms B had returned to work and whilst she was finding this difficult, it wasn’t impossible. Later this month a vocational clinical specialist

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reviewed Ms B’s medical information and said they thought her absence had been triggered by work-related stress. • In December 2024 Ms B became absent from work again. She spoke to an occupational health advisor and reported that her mental health had deteriorated and she was experiencing suicidal thoughts with plans of actioning this. The occupational health advisor reached out to Ms B’s GP based on this, asking if Ms B could be seen by the GP any sooner. • The GP note from 20 December 2024 records that the GP considered Ms B to have a deteriorating mental state with a high risk of self-harm. • Ms B’s psychiatrist wrote a report on 23 January 2025. The report provides detail about Ms B’s difficulties with her job. They suggested Ms B increased her medication and that they didn’t think Ms B was well enough to work at that time. Given the relevance of this report to Ms B’s claim and in the interest of achieving finality for both parties, I consider it appropriate for me to take this report into consideration within this provisional decision. However, I’m mindful it doesn’t appear Legal and General has received this report previously. So, I’ve attached this report and invite Legal and General to provide its comments in its response to the provisional decision if it wishes to do so. • In February 2025 Ms B spoke with an occupational health advisor who agreed Ms B was unfit to work at that time. • Ms B had further discussions with an occupational health advisor in May 2025 and July 2025. The reports state that Ms B had received a diagnosis of ADHD and ASD which resulted in her mood deteriorating and suicide attempts. Both reports stated they didn’t believe Ms B was fit for work. • On 4 August 2025 Ms B’s GP wrote a letter advising Ms B had been diagnosed with ADHD and ASD in April 2025 but depression remained the reason she was off work. They said Ms B had been off work for 12 months due to a serious depressive episode and remained unfit for work. Taking all of this into consideration, I think Legal and General’s decision to initially decline Ms B’s claim in November 2024, based on the medical evidence available to it at that time wasn’t unfair or unreasonable in the circumstances. Much of the medical evidence from this time was based on Ms B’s self-reporting and Ms B was in the process of completing a phased return to work. However, I’m not persuaded Legal and General has acted fairly or reasonably in its consideration of the claim following Ms B being unable to complete her phased return to work in December 2024. It appears Legal and General considered the deferred period as starting from when Ms B first became absent from work, which isn’t unreasonable. However, if an insured member is absent from work and doesn’t meet the policy definition of incapacity, but the medical evidence demonstrates a deterioration in the condition which later does support that they meet the policy definition of incapacity, there may be circumstances where I’d consider it fair and reasonable for the insurer to treat the deferred period as beginning at the later date. The insured would still need to demonstrate they met the policy definition of incapacity for the duration of the deferred period for any benefit to be paid, but I

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wouldn’t necessarily always agree that the deferred period has to begin on the first date they were absent from work in order for benefit to be payable, depending on the particular circumstances of the individual case. I’m not a medical expert, but I think the medical evidence from December 2024 onward points to a deterioration in Ms B’s condition. Whilst I again acknowledge it appears Legal and General hasn’t previously seen the psychiatrist report from January 2025, in this report the psychiatrist details Ms B’s symptoms which include self-harm and suicidal thoughts. They go on to say they don’t think therapy has been particularly effective to date and suggest Ms B increase her medication to double what she was currently taking. They say in their opinion Ms B wasn’t well enough to work at that time. Beyond this there are occupational health reports which record a deterioration in Ms B’s health including suicide attempts following her diagnosis of ASD and ADHD. The occupational health therapists are consistent in their opinion that Ms B wasn’t fit to return to work. In the letter from Ms B’s GP from August 2025, they say the phased return to work and diagnosis of ASD and ADHD both resulted in a deterioration in Ms B’s mental health. Legal and General has pointed to Ms B having attended the gym and language classes as part of its reasoning to decline Ms B’s claim. However, even if I were to consider this relevant to Ms B’s ability to carry out her occupation, I’ve not seen evidence these activities have continued throughout the period Ms B’s health appears to have deteriorated. I acknowledge Legal and General has asked its medical officer (MO) to review the medical evidence (aside from the psychiatrist report from January 2025) on three occasions and they don’t believe Ms B has met the policy definition of incapacity. However, I don’t think all of the reasoning given by the MO as to why they don’t consider Ms B has met the policy definition of incapacity to be persuasive. For example, the MO has said reported episodes of self-harm could be a coping response to occupational stress. However, the medical evidence reports suicide attempts following Ms B’s diagnosis of ADHD and ASD which was during a period Ms B wasn’t working and hadn’t been for a number of months. Similarly, the MO has said there is no indication Ms B has been hospitalised, had urgent psychiatric input or complex diagnostic features which would suggest a severe psychiatric illness. But the benefit being payable under the policy isn’t dependent on this. Benefit is payable if an insured member is unable to carry out their job role due to illness, which I think it’s reasonable to conclude could be demonstrated without requiring the insured to be hospitalised or having urgent psychiatric input. Whilst I’m not currently persuaded Legal and General has fairly declined Ms B’s claim based on the available evidence from December 2024, I don’t think it would be reasonable for me to conclude Ms B has met the policy definition of incapacity, and from which point. I’m not medically trained and so it wouldn’t be appropriate for me to do so. Additionally, I think Legal and General has fairly highlighted other relevant factors which would need to be taken into consideration, such as significant workplace stressors being recorded within the available medical evidence. And I note Ms B has since been diagnosed with ADHD and ASD which the medical evidence suggests caused a further deterioration in her health.

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Taking all of this into consideration, I think rather than issuing Ms B with a final response not upholding her complaint, it would have been fair and reasonable for Legal and General to obtain the opinion of a suitably qualified, independent medical expert (IME). I think given the complexities involved here, this would have enabled Legal and General to reach a fair outcome on Ms B’s claim. So, I’m currently satisfied that the fair and reasonable outcome for both parties, based on the specific circumstances of this complaint, is for Legal and General to appoint a suitably qualified IME to have an appointment with Ms B and also review all of the medical evidence. The IME can then determine whether they think Ms B has met the policy definition of incapacity and if so, from which point. For the avoidance of doubt, by ‘independent’, I mean someone who isn’t employed by Legal and General. Legal and General must then re-consider the claim based on the IME report. If any dispute arises about the outcome of the IME, or about any subsequent claim settlement due, this would need to be subject to a new complaint. As I’ve said, I think Legal and General were unreasonable to decline Ms B’s claim based on the evidence available to it and I think this has caused Ms B unnecessary distress. I think Ms B has clearly been going through a difficult period regardless, however I think Legal and General’s decision to decline her claim has exacerbated the distress she has experienced. Ms B has suffered the disappointment of her claim being declined, and a delay in her claim being finalised. Overall, I think Legal and General should pay Ms B £250 compensation to acknowledge the distress and inconvenience it has caused her.’ Ms B said she had nothing further to add to the provisional decision. Legal and General didn’t provide me with any further comments or evidence to consider. 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. As neither party has provided me with any further comments or evidence to consider I see no reason to reach a different outcome to the one I reached previously. So, I uphold this complaint for the reasons set out in my provisional decision. My final decision For the reasons I’ve outlined above, I uphold Ms B’s complaint about Legal and General Assurance Society Limited. I require it to: • Instruct and pay for a suitably qualified psychiatric independent medical expert to have an appointment with Ms B and review all of the available medical evidence alongside the terms of the policy. • It should specifically ask the independent medical expert to provide their opinion on whether they think Ms B has met the policy definition of incapacity, and if so, from which date. • Legal and General should then re-consider Ms B’s claim on the basis of the IME report.

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• Pay Ms B £250 compensation for the distress and inconvenience caused. Under the rules of the Financial Ombudsman Service, I’m required to ask Ms B to accept or reject my decision before 21 April 2026. Andrew Clarke Ombudsman

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