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

Decision detail

Summary

Mr S complained that CGI unfairly declined a pet insurance claim for his cat's vomiting treatment, citing a pre-existing condition exclusion based on vomiting episodes prior to policy inception. Mr S had informally adopted the cat from a previous owner and was unaware of its medical history. The ombudsman upheld the complaint, finding that the two vomiting episodes were unlikely to be the same condition based on persuasive veterinary opinion, and that Mr S could not have been aware of the pre-existing condition at policy inception given the circumstances of the adoption. CGI was directed to pay the claim with interest and £50 compensation.

The Ombudsman's reasoning

The ombudsman applied a two-part test for fair application of pre-existing condition exclusions: (1) whether the claimed condition is the same or directly connected to a pre-existing condition, and (2) whether the policyholder was aware something was wrong with the pet at policy inception. On the first test, the vet's opinion that the episodes were unlikely to be the same condition was persuasive and unopposed. On the second test, the circumstances of Mr S's informal adoption of the cat meant medical records were not available from the previous owner, and Mr S was unaware they had been transferred to his vet, so he could not have known about the pre-existing vomiting. Therefore, CGI had not fairly applied the exclusion.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website