Upheld: unfair claim decline; misapplication of pre-existing condition exclusion complaint against Casualty & General Insurance Company (Europe) Ltd

Decision detail

Summary

Mr H claimed under his pet insurance policy for ear polyp surgery for his cat in June 2025. C&G declined the claim as a pre-existing condition, noting the polyps were identified in October 2022. Mr H argued the condition should be covered as it had required no treatment in the 24 months prior to the claim. Unable to afford surgery without insurance, Mr H made the difficult decision to euthanise his cat. The ombudsman upheld the complaint, finding C&G had unfairly applied its policy terms by refusing to cover a condition that met the policy's own criteria for coverage (no treatment required in 24 months) and that Mr H could not reasonably have anticipated would require treatment. C&G was directed to pay £500 compensation.

The Ombudsman's reasoning

The ombudsman applied a fairness test beyond strict policy wording. Although ear polyps were technically present before the policy started, the condition had not required treatment for over 24 months (from October 2022 to June 2025), satisfying the policy's own terms for coverage. The ombudsman found it unfair to exclude the condition as pre-existing because: (1) Mr H could not reasonably have known in January 2024 that the polyps would require treatment, given they were asymptomatic for 15 months after diagnosis; (2) the policy explicitly allows coverage of conditions not requiring treatment for 24 months; and (3) C&G provided no fair explanation for refusing to cover the condition despite meeting the policy criteria. The ombudsman noted C&G's failure to apply the FOS's well-established approach to such cases.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website