Unum Limited · DRN-5931803

The complaint Miss K is unhappy with how Unum Limited handled a claim on her income protection policy. What happened Miss K had a group income protection policy through her employer. The policy is underwritten by Unum. In March 2023 Miss K was unable to work. Her employer submitted a claim in February 2024. Unum declined cover. They said the available medical evidence wasn’t enough to show Miss K met the definition of incapacity and the late notification of the claim from her employer had impacted their ability to establish her level of function during the deferred period. Miss K provided further medical evidence. In November 2024 Unum accepted cover and backdated the benefit to start from September 2023. In December 2024, Miss K’s employer informed Unum she may be made redundant. The following month Unum made a settlement offer of one year’s benefit under the policy which was accepted by Miss K’s employer. Unhappy that a settlement had been accepted without her involvement, Miss K referred a complaint to our service about everything that had happened. Our investigator said he thought Unum had handled the claim fairly, but they should pay £150 compensation for their poorly explained response to Miss K’s SAR request. Unum agreed, but Miss K asked for an ombudsman to review things. In summary she said: • The 12-month settlement was calculated on the wrong medical condition • She wasn’t included in the discussions about her settlement, and she now doesn’t have access to rehabilitation and return-to-work support offered under the policy • The initial claim decline was because of her employer’s late notification. This wasn’t her fault and she should be compensated for the loss and distress she suffered • The award for compensation for the SAR response should be higher The case has been passed to me to make a 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. I’ve considered all the available evidence and arguments to decide what’s fair and reasonable in the circumstances of this complaint.

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I may not respond to every point that has been raised - the informal nature of this service enables me to do that so I can resolve complaints with minimal formality. So I have focused on the key points of the case. 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 original claim decision Unum originally declined cover after reviewing the available medical evidence which was NHS records and an Occupational Health report. They said this wasn’t enough to show Miss K was incapacitated throughout the deferred period and beyond. I think Unum fairly assessed the information available to them at the time. I can see their medical officer reviewed the medical evidence and concluded there wasn’t enough to show Miss K was incapacitated. So it was reasonable for Unum to rely on this expert opinion and decline cover at that stage. Following the decline, I’m pleased Miss K was able to provide further medical evidence to Unum that changed their position, and they backdated the benefit. Miss K has explained she suffered financial loss and distress because Unum didn’t pay the claim initially. But for the reasons explained above, I think Unum was fair to decline cover based on the available medical evidence at the time, so I don’t think they need to do anything further here. Unum also said the late notification of the claim had impacted their ability to fairly assess the claim, so the claim was turned down on that basis. As the claim wasn’t submitted until February 2024, I think this was a reasonable conclusion to make in the circumstances. Had Unum been involved earlier they may have been able to assess Miss K’s functional capabilities in real time. It’s clear Miss K feels strongly that her employer submitting the claim late led to an unjust outcome for her. I can understand her point of view here, but any failings by her employer isn’t something I can hold Unum accountable for. My role is to consider if Unum fairly considered this claim based on the information they had. And for the reasons already explained above I think they acted fairly. I’m unable to comment any further on the actions and delays of Miss K’s employer as this is an employment matter. The settlement Miss K’s employer approached Unum in December 2024 asking them to calculate a settlement offer in the event Miss K was made redundant. I can’t say Unum did anything wrong by following the instruction of their policy holder. When Unum wrote to the employer about the settlement in January, they made it clear they’d be happy to continue with the existing arrangement, but Miss K’s employer agreed to the settlement instead. This isn’t a decision Unum is responsible for, and I haven’t seen anything to show they unfairly influenced what happened here. I appreciate why Miss K feels unhappy that a settlement was reached between Unum and her former employer without her involvement. This must’ve been frustrating and I can understand why she feels this was unfair. But I can’t say Unum did anything wrong by only communicating with their policy holder on this matter. Miss K’s employer is the policy holder here and they are the ones with the contractual relationship with Unum. The policy says in the event one of their employees is incapacitated, Unum will pay a benefit to the employer, and a sum is then passed on from the employer to

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the employee. So I don’t think the communication between Unum and Miss K’s employer was unfair or unusual. It isn’t Unum’s responsibility to communicate with Miss K about the sum of her benefit, any settlement figure, or indeed any redundancy discussions. Miss K has a relationship with her employer and is it at their discretion as the policy holder what they disclose to their employees. Miss K feels strongly that Unum would’ve offered a larger settlement to her employer if they’d considered fibromyalgia because it is a chronic and incurable condition. But Unum considered all the medical evidence they had access to at the time and obtained the opinion of their medical officer. The medical evidence included information about fibromyalgia and Unum referred to that condition in their notes. So I’m not persuaded Unum unfairly assessed the medical evidence before calculating their settlement. Miss K has referred to the rehabilitation support she is now unable to access under the policy. I understand this must be disappointing, but the policy holder is Miss K’s former employer, and as she is no longer employed by them, I can’t ask Unum to do anything further here under their policy. The SAR response Our investigator said Unum should pay £150 compensation because their response to Miss K’s SAR request could’ve been better. He said Unum’s poor explanation was frustrating for Miss K and it caused her inconvenience having to chase them for a clearer response. Unum agreed to this, but Miss K has said she doesn’t think the compensation is high enough. I’ve carefully considered how Unum handled the SAR request and they way they communicated with Miss K about this. I agree with the investigator that Unum should have been clearer in their response, and this caused frustration for Miss K. But I think £150 compensation goes far enough to rectify this error and take account of the timescale involved and inconvenience caused to Miss K. Putting things right Unum Limited need to put things right by: • Paying £150 compensation to Miss K for the impact of their poor communication in their SAR response My final decision I uphold this complaint against Unum Limited and direct them to put things right in the way I’ve outlined above. Under the rules of the Financial Ombudsman Service, I’m required to ask Miss K to accept or reject my decision before 24 April 2026. Georgina Gill Ombudsman

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