Not upheld: claim denial and policy interpretation complaint against Antares Insurance Company Limited

Decision detail

Summary

Mr H claimed on his pet insurance policy for dental treatment his cat required for a cracked tooth caused by feline odontoclastic resorption lesion (FORL). Antares declined the claim on the basis that the policy only covers dental treatment resulting from accidents, and this condition was not accident-related. Mr H argued the policy was ambiguous as it did not explicitly exclude non-preventable dental conditions, and that ambiguity should be read in his favour. The ombudsman found the policy terms were clear and unambiguous, explicitly excluding dental treatment required due to illness, which includes FORL as a disease. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman found the policy terms were clear and unambiguous. The policy explicitly excludes dental treatment required due to illness, and FORL is a disease falling within that definition. The policy only covers dental treatment when due to an accident, which was not the case here. The ombudsman rejected Mr H's argument that ambiguity should be read in his favour, finding the exclusion was clearly stated.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website