Upheld: Travel / life insurance claim disputes complaint against Convex Insurance UK Limited
Financial Ombudsman decision DRN-4655000 of 2024-03-21T00:00:00+00:00. Travel / life insurance claim disputes complaint against Convex Insurance UK Limited. Outcome: Upheld.
Decision detail
| Reference | DRN-4655000 |
|---|---|
| Decision date | 2024-03-21T00:00:00+00:00 |
| Firm | Convex Insurance UK Limited |
| Product | Other regulated product |
| Claim type | Travel / life insurance claim disputes |
| Outcome | Upheld |
| Remedy | Convex Insurance UK Limited must pay Mr and Mrs L's claim for the 17 February 2023 and 31 March 2023 veterinary invoices subject to policy limit and applicable excess, less: (1) the £90 examination/EquiGait fee for February 2023 if already paid; (2) the cost of blood test and laboratory work for Cushing's Disease. Interest at simple rate of 8% per annum from date invoices were paid to date of settlement. Tax deduction certificate to be provided if requested. |
Summary
Mr and Mrs L held equine insurance with Convex for their horse. In June 2022, the horse was diagnosed with medial patellar ligament desmitis (left stifle) and Convex paid the claim. The vet recommended a rehabilitation programme involving controlled exercise. In February and March 2023, the vet conducted follow-up consultations as part of the ongoing rehabilitation, including EquiGait analysis and medication. Convex refused to pay these invoices, arguing they were new claims requiring new diagnosis and potentially covered by the degenerative disease exclusion. Mrs L complained that the consultations were continuation of the original claim. The ombudsman upheld the complaint, finding the specialist vet's evidence clearly linked the 2023 consultations to the 2022 injury and that Convex had failed to prove an exclusion applied. Convex was ordered to pay the invoices (excluding Cushing's Disease tests) plus interest.
The Ombudsman's reasoning
The ombudsman found that Mrs L had demonstrated an insured event occurred by showing the February and March 2023 consultations were part of the ongoing rehabilitation programme for the June 2022 stifle injury, not new claims. The vet's evidence clearly linked the 2023 consultations to the original condition. Once an insured event is shown, the burden shifts to the insurer to prove an exclusion applies. Convex failed to do so. The ombudsman found Mrs L's specialist vet's evidence more persuasive than Convex's paper-based vet review, particularly given the treating vet's direct examination and specialist expertise in equine rehabilitation. The horse had not returned to normal work and health by December 2022 (had not resumed canter), so the period of recovery continued into 2023. The EquiGait analysis was a legitimate diagnostic tool used consistently throughout the rehabilitation programme, not maintenance or reassurance. Cartrophen was prescribed for the stifle injury, not as treatment for an excluded degenerative condition.
How this compares
| Group | Decisions | Uphold rate |
|---|---|---|
| Convex Insurance UK Limited, all decisions | 3 | 67% |
| Travel / life insurance claim disputes, all decisions | 19,183 | 32% |
| Other regulated product, all decisions | 51,105 | 30% |
Source
Read the original decision on the Financial Ombudsman Service website