TPO upholds ill health complaint against NHS

The Pensions Ombudsman (TPO) has upheld an ill health benefits complaint against the NHS Pension Scheme, ordering the scheme to review its decision.

'Mr N' complained that the scheme had not considered his application for early deferred benefits (EPDB) properly.

Having left the NHS in 2000, Mr N subsequently applied for EPDB on the grounds of ill health in 2017 (aged 56) as he was suffering chronic depression and anxiety.

The claim for EPDB was supported by his attending doctor, Dr Kumar, who confirmed that Mr N had been seen by a specialist, and stated: “this gentleman will remain depressed in the foreseeable future.”

However, following a review of the case by NHS Pension’s medical adviser (MA) the claim was declined on the basis that he had not demonstrated permanent incapacity for regular employment, arguing that treatment would likely help Mr N.

After appealing through the scheme’s two-stage internal dispute resolution (IDR) procedure in July 2017 the scheme obtained the opinion of another MA.

Whilst acknowledging Dr Kumar’s opinion, the MA agreed with the original decision and the scheme turned down Mr N’s appeal in September 2017.

Mr N provided a copy of a letter to the scheme (dated 16 December 2017) in February 2018 that was presumed to be Mr N’s IDR stage 2 appeal.

However, the scheme said it did not receive the letter in time, and noted that subsequent requests were received more than six-months after the IDR stage one decision.

In its determination, TPO ruled that the scheme should have sought clarification before relying on the MA’s recommendations, pointing out that a lack of follow up with Dr Kumar or Mr N’s psychiatrist had left some information unknown, such as which of the MA suggested treatments had already been tried.

The deputy pensions ombudsman, Karen Johnston, ruled that the decision had not been reached in “a proper manner”, stating that this amounted to “maladministration by NHS Pensions”.

The scheme was given 14 days from the determination to request further details from Dr Kumar and Mr N’s psychiatrist and a further 14 days after receiving this information to ask the MA for a further assessment.

The scheme has also been ordered to pay £500 for distress and inconvenience.

This also follows a similar ill health complaint against the Central Networks Group of the Electricity Supply Pension Scheme, in which TPO also ruled that the scheme should obtain further clarification from the medical adviser of the scheme.

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