Not upheld: claim rejection and claim handling complaint against Wakam

Decision detail

Summary

Mr G complained that Wakam unfairly declined his pet insurance claim for dental treatment for his newly-added cat H. Wakam initially rejected the claim citing a pre-existing condition exclusion but later accepted it could not confirm pre-existing status and instead relied on the policy's 14-day waiting period exclusion for illness. The ombudsman reviewed veterinary notes showing dental issues were documented within the first 14 days of cover and were linked to the later claim for FORL treatment. The ombudsman upheld Wakam's decision to decline the claim as the policy clearly excludes illness suffered in the first 14 days, and found the £100 compensation already paid was adequate for the claim handling delays.

The Ombudsman's reasoning

The ombudsman found that veterinary notes from within the 14-day waiting period clearly documented dental issues (tartar, chipped teeth, and planned extractions) that were linked to the later claim for FORL treatment. The policy explicitly excludes illness suffered in the first 14 days of cover. Although Mr G was not aware of the pre-existing condition and it would not be reasonable to delay veterinary treatment, the identification of illness within the waiting period meant the claim was not covered. Wakam's initial reliance on the pre-existing exclusion was incorrect, but its ultimate decision to decline based on the 14-day exclusion was fair and reasonable.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website