Upheld: Motor insurance, claim handling complaint against Convex Insurance UK Limited

Decision detail

Summary

Ms N claimed on her equine insurance policy for veterinary treatment of squamous cell carcinoma in her horse's penis, costing over £4,000. Convex declined the claim based on a policy exclusion for skin nodules and abnormalities, applied due to pre-purchase examination findings. The ombudsman found that Convex's initial veterinary evidence was unclear and inconclusive, making their decision to decline the claim unfair despite the exclusion ultimately being applicable based on later clarified evidence. Convex was ordered to pay £350 compensation for the stress and inconvenience caused by their unfair handling of the claim.

The Ombudsman's reasoning

The ombudsman determined that while Convex was ultimately entitled to apply the exclusion based on clarified veterinary evidence showing the squamous cell carcinoma arose from skin abnormalities, they acted unfairly by declining the claim based on unclear and inconclusive evidence initially. The ombudsman found that Convex, as insurers reliant on veterinary evidence, failed to provide a sound basis for their decision, causing Ms N stress and inconvenience. The ombudsman rejected arguments that the exclusion itself was unfair, noting it is not the ombudsman's role to determine what risks insurers take on, only whether they apply exclusions fairly.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website