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ombudsman news

issue 106

November/December 2012

pet insurance

Pet insurance is designed to help consumers pay for unexpected vet's bills and related treatment. Pet insurance policies are very popular. But like most insurance policies, they do not cover every eventuality. The policies often include restrictions that may not always be obvious to consumers. The problems we see usually arise when an insurer refuses to pay a claim. This may happen because the insurer says that:

  • the pet already suffered from the condition when the policy was taken out
  • the pet first showed signs of the condition shortly after the policy was taken out, and the policy did not cover conditions arising so soon
  • the consumer was claiming for treatment that took place more than 12 months after the condition became apparent, and the cover only lasted for 12 months after the first sign of the condition
  • the consumer failed to disclose important information about the pet's medical history when they took the policy out.

Cases involving pet insurance are dealt with by a specialist team of experienced people. When we consider these cases, we look at the policy wording and any other relevant documents. We also take into account any medical evidence provided by vets - for example, clinical notes and written submissions.

In June 2012, we published a final decision on our website about a case involving an insurer's decision to withdraw from the pet insurance market. Their decision to withdraw had meant that a consumer - who had believed that her pet would be covered for life - would need to look elsewhere for her insurance. If she had chosen to take out a new policy independently, her pet's "pre-existing medical condition" may not have been covered - and she would have been left to foot the bill for her any treatment for her pet's condition in the future.

Essentially, we told the insurer that its description of the policy as "life-long" was misleading - and that if it had communicated earlier and more clearly with its customer, she would have been able to make alternative arrangements for her pet. As it was, we were pleased the insurer responded to our findings by offering their customer a new policy - that would give the same cover for her pet's condition as her original policy.

That case was covered extensively in the media. So we have chosen the case studies that follow to illustrate some different issues, including:

  • "pre-existing medical conditions"
  • a "pre-disposition" to a medical condition
  • a rejected claim for the loss of a horse - where the decision to put the horse down was not in line with British Equine Veterinary Association (BEVA) guidelines.

Our online technical resource, available on our website, contains more information about our approach to cases involving pet insurance.

issue 106 index of case studies

  • 106/7 - complaint about a "pre-existing medical condition"
  • 106/8 - complaint about a claim rejected because of a "pre-existing medical condition"
  • 106/9 - claim is rejected because of a"pre-existing medical condition" - which had been diagnosed but not treated
  • 106/10 - claim for loss of a horse - rejected because it was not carried out in line with "BEVA" guidelines
  • 106/11 - claim is rejected because of"pre-disposition" to a medical condition

106/7
complaint about a "pre-existing medical condition"

Mrs R's dog, Bella, had a recurring hip problem. Mrs R had an insurance policy in place for Bella, and had made a successful claim for the cost of some treatment. But she was unhappy with the way she had been treated by her insurer, and decided to switch to another provider. So she phoned a different insurer, spoke to an adviser and took out a policy. She then cancelled her original policy.

About a year later, Bella needed more treatment for her hip problem - and Mrs R put in a claim to cover the cost of the vet's fees. But the insurer turned down her claim on the grounds that Bella's treatment had been for a "pre-existing medical condition", which the policy did not cover.

Mrs R was unhappy with this and complained to the insurer. She said that she had asked specifically whether Bella's hip problem would be covered - and had been told that it would. She added that she would definitely not have taken the policy out if she had been told that the condition would not be covered.

In its response, the insurer accepted that Mrs R had told them about Bella's hip problem. But it did not agree that it had said it would cover the condition. The insurer also said that Mrs R should have read the policy terms carefully. Mrs R was not sure what else she could do, so she decided to refer the matter to us.

complaint upheld
The insurer could not give us a recording of the phone conversation that had taken place between Mrs R and the adviser. But it did give us a note that the adviser had taken during the call. Although the note was not particularly detailed, it did indicate that the representative had "advised the consumer of the terms and conditions".

However, when we looked into Mrs R's circumstances, we doubted the fact that she would have taken out a policy that would not cover Bella's condition. After all, she had known that Bella's condition would have been likely to continue, and that she might have needed to claim under her new policy. We thought it was likely that if Mrs R had been given the full picture by the insurer, she would have kept her existing policy - and continued to be covered by it, rather than take out a new one and risk not being covered.

In these circumstances, we told the insurer to pay the claim.

106/8
complaint about a claim rejected because of a "pre-existing medical condition"

For two years, Mr V had held an insurance policy for his cat, Florence. When Florence had to have a tumour removed, Mr V made a claim under the policy to cover the vet's bill.

Mr V's insurer turned down the claim. It said that Florence's treatment had related to a "pre-existing medical condition". It also said that when Mr V had taken the policy out, he should have mentioned that Florence had already seen the vet about two lumps - and that had he done so, it would have applied an additional exclusion to the policy that related specifically to tumours, cysts and abscesses.

Mr V thought this was unfair, and contacted the insurer to complain. He said that when he had taken the policy out, the vet had not diagnosed the cause of the Florence's lumps - and had simply advised him to monitor her. Mr V also said that the lumps had not grown or changed by the time he took out the policy - so he had not thought he had needed to disclose them. Mr V also argued that he had given the insurer the contact details for Florence's vet - and that the insurer could have investigated the situation before it had set up the policy.

complaint not upheld
In effect, Mr V's insurer was retrospectively applying the exclusion for tumours, cysts and abscesses. So we needed to decide whether this was fair and reasonable in the circumstances. When we listened to the phone conversation during which Mr V had taken out the policy, we found that the insurer had asked him whether Florence had "shown any signs of an illness or injury or been unwell, either now or in the past?" Mr V had answered "No."

We also looked at Mr V's policy documents. They defined a "pre-existing medical condition" as "an injury or illness that is caused by, relates to, or results from, an injury, illness or clinical signs your pet had before the section was added to your insurance". We thought that this explanation was clear - and that Mr V should have realised that Florence's condition would not be covered by the policy.

In these circumstances, we did not uphold the complaint.

106/9
claim is rejected because of a"pre-existing medical condition" - which had been diagnosed but not treated

Mr L's dog, Ivy, was diagnosed with a dislocated knee cap in 2007. She needed some treatment, and Mr L claimed under the insurance policy he had in place for Ivy. His insurer rejected his claim on the grounds that it related to a "pre-existing medical condition" - because Ivy's condition had been diagnosed in 2004. Mr L complained, saying that Ivy had never been treated for anything like this before. When the insurer stuck to its original position, Mr L asked us to investigate.

complaint not upheld
When we reviewed the evidence, we found the vet's notes showed that Ivy had been diagnosed with the same condition in 2004. However, it had not been treated. When we asked the vet why, she told us that she had not expected the condition to present Ivy with any problems in the future.

We explained to Mr L that even though Ivy had not been treated for this condition in 2004,"pre-existing medical conditions" do not just relate to treatment. Mr L's policy document had defined a pre-existing medical condition as "any condition or symptoms or signs of injury, illness or disease, occurring or existing in any form prior to the start of this insurance". So we were satisfied that the insurer had not acted wrongly in turning down Mr L's claim - and we did not uphold the complaint.

106/10
claim for loss of a horse - rejected because it was not carried out in line with "BEVA" guidelines

Mr C owned a horse, Amber. Unfortunately, Amber was suffering from a degenerative joint disease in one of her legs, and she went lame. Mr C phoned his insurer to ask whether his policy would cover him for the loss of the horse. An adviser went through Mr C's policy with him. She explained that if he made a successful claim, the policy would pay a lump sum benefit on his horse's death. The adviser also went through the relevant criteria relating to euthanasia. After the conversation, she sent Mr C a letter and a claim form.

Amber's pain increased, and eventually, Mr C decided that she was suffering too much. He contacted his vet, who came out and put the horse down at Mr C's request. Mr C made a claim under his insurance policy for the loss of the horse. His claim was turned down. The insurer said that the euthanasia had not met the conditions set out in guidelines given by the British Equine Veterinary Association (BEVA). The insurer also pointed out to Mr C that the policy said that for a euthanasia claim to be valid, the insurer would need to give written consent before the horse was put down.

Mr C complained to the insurer, saying that the BEVA guidelines were not mentioned in his policy terms and conditions. He pointed out that his policy did allow him to make a valid claim without written permission if the horse was slaughtered on humane grounds. He argued that he had acted in the best interests of his horse - which was in pain - and he said that he had been given written consent from the insurer when they had written to him enclosing the claim form. When the insurer rejected Mr C's complaint, he referred the matter to us.

complaint not upheld
We explained to Mr C that the British Equine Veterinary Association published its guidelines to help with insurance claims. The guidelines say that it is up to the attending vet to decide whether to advise the owner if the horse should be put down - regardless of whether or not the horse is insured. They also say that for a horse to be put down, it must be shown that "no other options of treatment are available to that horse, at that time."

When we reviewed Mr C's policy documents, we found that they did not mention the BEVA guidelines explicitly. However, we decided that this was not crucial to the case. The policy did make it clear that the destruction of a horse must be "immediately necessary" and that it would only be covered if "no other treatment was available". We would usually use the BEVA guidelines as an indication of how this should work in practice.

To establish whether this had been the case, we looked at the evidence supplied by Mr C's vet - as well as the insurer's vet. They agreed that Amber's condition was possibly treatable - and that she could have been given anti-inflammatories and retired to a paddock. So she did not fit the guidelines or the policy terms for a claim.

We also needed to establish whether the insurer had given written consent for the horse to be put down. We noted that the insurer's letter to Mr C - which he had argued had given written consent for Amber to be put down - had said that the insurer would "need to receive a fully completed claim form, before we can consider the validity of your claim." So we concluded that the insurer had not given written consent before the horse was put down.

In these circumstances, although we sympathised with Mr C for the loss of his horse, we took the view that the decision to put Amber down had not met the conditions set out in his policy. We did not uphold the case.

106/11
claim is rejected because of "pre-disposition" to a medical condition

In 2010, Miss R's dog, Haversham, had surgery to remove two mammary lumps and a growth in her urinary tract. Earlier in the year, Miss R had taken out an insurance policy for Haversham - and she made a claim under the policy to cover some of the vet's fees. The insurer turned down the claim. It said that Haversham had a "pre-disposition" to this condition. The insurer also pointed out that when Haversham had been examined by the vet in 2006, the vet had found a nodule in her right mammary gland. Although the vet had decided not to treat the condition, Miss R's insurer said that she should have told it about her dog's history when she took out the policy.

Miss R complained to the insurer. She said that it had not asked her any questions about her dog's medical history when she took out the policy. And she said that even if the insurer had asked her about it, she would not have mentioned anything because back in 2006, the vet had assured her that the nodule was not serious. She added that when she took out the policy, she had no reason to believe that Haversham would be likely to experience this sort of problem. When the insurer refused to reconsider, Miss R referred the matter to us.

complaint upheld
We looked at the evidence given to us by both parties. This included the paperwork that Miss R had filled in when she had taken out the policy. We found that although Miss R had ticked a box on the application form to confirm she had understood that Haversham would not be covered for "pre-existing medical conditions", she had not been asked explicitly about Haversham's medical history.

We also reviewed a statement supplied by Miss R's vet. The vet said that the nodule he had found in 2006 was of "such insignificance" that unless Miss R had been asked for Haversham's full medical history when she took out the policy, he would not have expected her to mention it. He also said that the mammary lumps and the tumour in the dog's urinary tract were "completely unrelated" to the condition he had identified in 2006.

In these circumstances, we did not think that Miss R could reasonably be expected to have offered her insurer details about Haversham's medical history. We upheld the complaint - and told the insurer to pay the claim.