Aviva Life & Pensions UK Limited · DRN-6176927

The complaint Mr H is unhappy with the term Aviva Life & Pensions UK Limited relied on to decline his income protection claim. What happened Mr H was a beneficiary under his previous employer’s group income protection policy with Aviva. In June 2024, Mr H was told he was at risk of redundancy and became absent from work the following month, owing to increased symptoms of anxiety and depression. Mr H said Aviva declined his claim because his absence was caused by workplace issues that triggered his longstanding mental health conditions. Mr H said Aviva’s terms are discriminatory as whilst he understands it doesn’t pay claims resulting from workplace matters, his medical conditions place him at an increased likelihood of bringing claims of that nature. He’d like Aviva to accept its terms are discriminatory. Aviva said it declined Mr H’s claim because he didn’t meet the definition of incapacity. It said although there’s evidence he suffered with depression and anxiety, there wasn’t enough evidence to explain why this meant he was unable to meet the demands of his role. Aviva also said where there’s evidence of an absence caused by workplace matters, there’s no cover under the policy. It disagreed this was discriminatory because it applies to all claims and not just Mr H’s. Our investigator didn’t uphold this complaint. She said Aviva had persuasively shown Mr H hadn’t satisfied the incapacity term. She also noted the policy doesn’t cover absences caused by workplace issues. She highlighted the evidence showed Mr H’s absence was caused by his redundancy, which in turn triggered his mental health conditions. Mr H, unhappy with that, asked for an ombudsman to review his complaint. In summary, he said the policy exclusion is discriminatory because consumers, like him, that suffer with similar medical conditions are more likely to become ill due to workplace matters. Mr H said he’s therefore substantially disadvantaged as a result of that. And so, it’s now for me to reach 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’ve decided not to uphold it and for broadly the same reasons as our investigator. I don’t think the medical evidence supports that Mr H’s absence from work was caused by a debilitating medical condition that incapacitated him. I’ll explain why. The relevant rule that applies in this case comes from the Insurance Conduct of Business Sourcebook and says Aviva must handle claims promptly and fairly and must not reject a claim unreasonably.

-- 1 of 3 --

Although I may not respond to every point Mr H has raised, I want to reassure him I’ve considered everything he’s said. The informal nature of this service enables me to do that so I can resolve complaints with minimal formality. Mr H has made it clear the crux of his complaint is about the policy exclusion itself and not the assessment and outcome of his claim. But I must consider Aviva’s actions, relevant to the decision on his claim, so I’ll be making a finding on that too. Mr H said Aviva’s exclusion is unfair as it places him at a disadvantage when considered more broadly in the context of consumers that don’t suffer with his mental health conditions. To be clear, the exclusion says: “Absence caused by workplace matters, such as a relationship breakdown, workplace demands or failure to make reasonable adjustments are not covered” I should say this is a standard position across the relevant insurance industry as income protection policies generally only pay valid claims that aren’t caused by workplace matters. I wanted to acknowledge Mr H’s concern he is at an increased risk of experiencing workplace issues, because of his medical conditions. He, therefore, feels this exclusion disproportionately affects him and others with his conditions. But this isn’t the primary reason Aviva gave for declining Mr H’s claim. Aviva’s final response letter explained the medical evidence didn’t show Mr H was suffering with a medical condition that rendered him totally incapacitated. And having considered its reasons for saying that, I think its position is reasonable. Whilst it’s clear he began suffering with symptoms of anxiety and depression in June 2024, he was still functionally able to continue working. The GP records show the onset of his symptoms were caused by the announcement that his role was at risk of redundancy. But the records also show Mr H was well enough to actively look for employment elsewhere at that time. Aviva highlighted that and said this shows Mr H didn’t satisfy the incapacity term on that basis as he was functionally able to consider alternative employment, which I thought was a reasonable conclusion to draw in the circumstances. Mr H’s medical records show despite his long-standing mental health conditions, he was able to continue working for most of that time and it wasn’t until July 2024, he was unable to return to work in any capacity. Aviva said the trigger for that absence was, understandably, the news of his redundancy. Having carefully considered Mr H’s medical records, I’m persuaded that was indeed the case here. Mr H was issued FIT notes for depression and anxiety, but a diagnosis alone doesn’t persuasively demonstrate Mr H was unable to fulfil the duties of his role. Aviva said there’s not enough objective medical evidence to explain that and having reviewed Mr H’s medical records, I agree. It’s for these reasons, I think Aviva’s decision to decline the claim is fair, because Mr H hasn’t met the incapacity criteria under the policy. The relevant policy terms say about incapacity: “Own, the members inability to perform on a full and part-time basis the duties of their job role as a result of their illness or injury” This means Mr H must show, through objective medical evidence, that he’s unable to perform the duties of his role. It’s because the available medical evidence doesn’t persuasively explain why that was the case Aviva can fairly decline his claim.

-- 2 of 3 --

The other medical issues Mr H experienced also didn’t incapacitate him in the way the policy required. I note whilst he was off work, he underwent a surgical procedure to treat a hernia, which was successful. Mr H wasn’t actively at work at that time and so Aviva didn’t need to consider whether that issue caused incapacity. Workplace matters not covered Mr H has made several arguments about why he feels Aviva’s terms are discriminatory. He referred to the Equality Act and said other consumers with similar conditions would be disproportionately affected by Aviva’s exclusion for workplace matters. I understand the argument he’s making, but I’m unable to make a finding on whether Aviva has breached the Act as this is a determination only the Courts can make. In Mr H’s case, Aviva didn’t rely solely on the exclusion to decline his claim as it primarily decided there wasn’t evidence of a condition that would render him functionally incapacitated. It’s because Aviva has persuasively shown that Mr H didn’t satisfy the incapacity term that I find it’s declined Mr H’s claim fairly. I, therefore, don’t need to make a finding on whether the workplace exclusion is discriminatory as this wasn’t the main reason Mr H’s claim was declined. My final decision For the reasons I’ve explained, I don’t uphold this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr H to accept or reject my decision before 14 April 2026. Scott Slade Ombudsman

-- 3 of 3 --