Partially upheld: claim declined - non-compliance with policy condition complaint against Red Sands Insurance Company (Europe) Limited

Decision detail

Summary

Mrs J claimed on her pet insurance policy for her cat's dental treatment, including treatment for feline odontoclastic resorptive lesions (FORLs) and tartar buildup. Red Sands declined the claim because the cat had not had an annual dental check-up within the last 12 months, as required by the policy. The Ombudsman upheld the complaint in part, directing Red Sands to pay for FORL treatment costs (as FORLs cannot be detected in routine checks) but allowing Red Sands to decline payment for tartar treatment (which would likely have been detected and treated earlier with annual check-ups). The remedy includes reimbursement of FORL treatment costs less excess plus 8% simple interest.

The Ombudsman's reasoning

While the policy term strictly required annual dental check-ups, the Ombudsman applied the usual FOS approach of considering whether non-compliance increased the risk of loss. The Ombudsman found that FORLs would be unlikely to be detected in a routine annual dental check and there was no evidence the condition was caused by or would have been treated earlier with such checks. Therefore, strict application of the policy term would be unfair for FORL treatment costs. However, the Ombudsman accepted that tartar buildup would likely have been detected and treated earlier with annual check-ups, so declining payment for scale and polish and tartar treatment was fair.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website