The High Court has ruled that James Holohan was entitled to income protection benefits after finding, on the balance of probabilities, that fibromyalgia left him unable to carry out his normal occupation as an insurance broker.
Mr Justice Michael White said the plaintiff came within the terms of his policy with Friends First Life Assurance Company Limited. The court ordered specific performance requiring future benefits accruing under the policy to be paid. It also noted that the parties had agreed the actuarial calculation of his net loss since the benefits were discontinued. The judgment does not state the amount of that loss.
The case was heard over five days in February 2014. Mr Holohan’s policy, effective from March 2006, covered him if illness or accident left him totally unable to perform his normal occupation and he was not doing another occupation for reward. He stopped work in April 2009 and was diagnosed with fibromyalgia. The insurer initially accepted his claim, with payments beginning in October 2009 after a 26-week deferred period.
Following medical reviews and a two-day chronic pain abilities determination assessment in May 2011, the insurer concluded that he no longer met the policy’s disability definition and ended the benefit after a phased payment. It rejected his claim in August 2011. Mr Holohan disputed that decision and brought proceedings seeking a declaration that the insurer had breached the contract.
The court heard opposing medical opinions. Doctors who treated or assessed Mr Holohan for the plaintiff said his fibromyalgia was genuine and prevented him from returning to his former work. The insurer’s occupational medicine specialist considered him fit to attempt a return. The court described the medical evidence as substantially conflicting, while noting that all medical experts accepted he had fibromyalgia.
The insurer’s assessor, David Newman, reported inconsistencies in the functional and cognitive testing and concluded that Mr Holohan’s demonstrated abilities did not represent his true capabilities. The judge accepted the CPAD process as a recognised assessment tool and had concerns about some results, particularly the cognitive testing. But he preferred the tender-point testing by the plaintiff’s medical witnesses and considered the full body of evidence. He found that Mr Holohan had not deliberately or recklessly misrepresented the severity of his condition.
The judge accepted the plaintiff’s medical evidence as persuasive and concluded that he met the policy test. The ruling resolves the contractual claim at the High Court; the judgment does not specify a quantified damages award or address any appeal.