Upheld: unfair claim rejection based on pre-existing condition exclusion complaint against Casualty & General Insurance Company (Europe) Ltd

Decision detail

Summary

Mrs W claimed on her pet insurance policy for treatment of her dog's allergic ear problem. C&G rejected the claim as relating to a pre-existing condition, citing treatment for otitis externa in November 2023, prior to the December 2023 policy inception. The ombudsman upheld the complaint, finding that C&G failed to demonstrate the underlying cause of both conditions was the same. The vet's November 2023 notes showed no indication of allergic disease, the allergic diagnosis came months later, and the clinical presentations differed markedly. Since otitis externa has multiple common causes, C&G had not met its burden of proof to apply the exclusion. The claim must be paid subject to policy terms with 8% simple interest on amounts already paid.

The Ombudsman's reasoning

Where an insurer relies on an exclusion to decline a claim, the burden is on the insurer to show on balance that it applies. For the pre-existing condition exclusion to apply, the underlying cause of both the November 2023 and claimed ear problems must be the same. C&G relied primarily on symptom similarity, but the clinical presentations differed markedly. Critically, there was no indication of allergic disease in the November 2023 notes, and the allergic diagnosis came months later. Otitis externa has multiple common causes, so subsequent allergic diagnosis does not prove that was the cause in November 2023. C&G obtained no independent veterinary evidence and failed to demonstrate on balance that the conditions were linked.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website