Aviva Life & Pensions UK Limited · DRN-6117172

The complaint Miss J has complained that Aviva Life & Pensions UK Limited (‘Aviva’) unfairly declined her claim. What happened Miss J has a group income protection insurance policy, underwritten by Aviva. She became unwell and absent from work and made a claim but Aviva declined the claim as it said Miss J was suffering from work related stress and this was excluded under the policy terms. Miss J appealed and complained. Unhappy with Aviva’s response, she referred her complaint to the Financial Ombudsman Service. Our investigator looked into the complaint but didn’t think Aviva had unfairly declined the claim. Miss J disagreed and asked for an Ombudsman’s decision. And so the case has 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. Having done so, I don’t think this complaint should be upheld. And I’ll explain why. But firstly, I'd like to say I am really sorry to hear of Miss J’s ill health and the circumstances which led to her 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 policy pays benefit if Miss J is unable to work due to illness or injury throughout the deferred (waiting) period of 26 weeks and beyond. The definition of incapacity which applies to Miss J is as follows: “Suited. The member’s inability to perform on a full and part time basis the duties of their job role and other occupations for which they are suited by reason of education, training or experience, as a result of their illness or injury.” The policy also has an exclusion which says: “Absence caused by workplace matters, such as a relationship breakdown, workplace demands or failure to make reasonable adjustments are not covered.”

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So Miss J has to show, through objective medical evidence that she is unable to work due to an illness or injury for a period of at least 26 weeks. And absences related to workplace matters are not covered. Aviva declined the claim on the basis that Miss J’s absence was primarily caused by workplace problems and work-related stress. And it has relied on the medical evidence which refers to Miss J’s workplace demands and problems. It has also said that even without the workplace stress, it doesn’t have sufficient medical evidence to show that Miss J’s absence was due to an illness which prevented her from working altogether. I have reviewed the available medical evidence to consider whether Aviva acted reasonably by relying on it. And I think it has. I will summarise what the medical evidence shows. I note Miss J was experiencing symptoms before she became absent from work and continued to work whilst unwell. She reported her symptoms were due to her job and work- related stress. Miss J became absent in September 2024. And before her absence, between July 2024 and September 2024 Miss J had consulted with her GP about work stress, anxiety attacks and panic attacks. She also reported fainting episodes and chest pain amongst other things. After September 2024, the medical evidence shows that she’d had blood tests and a thorough examination abroad. Her blood tests and CT scan results were normal. Her GP noted “extreme burn out” and that Miss J planned to find new work. Her GP continued to sign her off and in January 2025, Miss J said she had a follow up appointment with her treating specialist abroad due to an increase in fainting episodes which she thought might be related to her return-to-work date. Her consultant could find no underlying cause and felt it was related to her burn out. Her GP made a referral to the neurology team in February 2025. Taking all of the above into consideration, the medical evidence suggests that Miss J’s symptoms and absence were caused by work-related stress and there was no medical reason for her illness by February 2025. Although her GP made a referral to a specialist, Aviva will assess the available evidence from the deferred period as Miss J has to be unwell due to an illness or injury throughout that time and beyond in order to be eligible for benefit. In this case, there is evidence that she was suffering from work related stress throughout the deferred period which isn’t an illness. The NHS says stress is a reaction to a set of circumstances. Without any further objective medical evidence to show that Miss J had an illness which prevented her from working throughout the deferred period, I don’t think Aviva unfairly declined this claim. Miss J has suggested that there is another root cause for her absence as she has not recovered despite being absent from work. However, I note there is reference to thoughts of work causing symptoms and specifically around a return to work date as set out above. It is up to Miss J to prove her claim and provide the necessary medical evidence to Aviva. Given the context around her absence and reported symptoms being related to work place matters, I don’t think Aviva’s decision to decline the claim was unfair or unreasonable. Miss J has provided further and new medical evidence after the deferred period and Aviva’s final response letter. She says Aviva was aware that she was having further medical appointments and it should have waited for the outcome of ongoing investigations and the additional medical evidence before reaching a decision. However, Aviva is expected to reach a decision promptly based on the date of Miss J’s absence and the relevant deferred period. As Miss J has new medical evidence which Aviva may not have seen yet, she should send it to Aviva, if she hasn’t already done so. I can’t comment on any new evidence which Aviva

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hasn’t seen or hasn’t had an opportunity to respond to. If Miss J remains unhappy with Aviva’s response to the new evidence, she would be able to raise a new complaint about that. For the sake of completeness, Miss J has also complained about a phone call with Aviva which she says was recorded without her consent. However, Aviva has provided a consent form in which Miss J agreed to telephone calls being recorded and so I don’t uphold this complaint. Miss J was also unhappy that Aviva hadn’t provided her with the policy documents but as her employer is the policyholder, it would be up to her employer to decide whether to provide the documents to her. I am really sorry to disappoint Miss J but I don’t think Aviva unfairly declined her claim based on the medical information available to it which covered the deferred period. 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 Miss J to accept or reject my decision before 1 April 2026. Shamaila Hussain Ombudsman

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