Not upheld: claim rejection based on pre-existing condition exclusion complaint against Wakam

Decision detail

Summary

Miss D claimed on her pet insurance policy with Wakam for surgery for her dog's BOAS in May 2025. Wakam rejected the claim citing the pre-existing condition exclusion, arguing the dog had shown symptoms of BOAS prior to the policy start date of 2 January 2025, although formal diagnosis did not occur until March 2025. Miss D disputed this, arguing there was no evidence the pre-policy symptoms were caused by BOAS and that Wakam was making assumptions. The ombudsman reviewed the veterinary evidence and found that the dog had been treated for breathing difficulties and regurgitation from July 2024 onwards, which are consistent with BOAS, and that these symptoms continued at the point the new policy was taken out. The ombudsman concluded it was reasonable for Wakam to conclude these pre-policy symptoms were related to the subsequently diagnosed BOAS and fair to apply the pre-existing condition exclusion, particularly as the policyholder was aware of the issues and had already sought treatment.

The Ombudsman's reasoning

The ombudsman found that although BOAS was not formally diagnosed until after the policy start date, the veterinary evidence showed the dog was displaying symptoms consistent with BOAS (breathing difficulties and regurgitation) prior to the policy being taken out. The policy definition of pre-existing conditions does not require a formal diagnosis to have been made, only that signs or symptoms were present. The ombudsman concluded it was reasonable for Wakam to conclude the symptoms prior to the policy start date were related to the BOAS subsequently diagnosed. Additionally, the ombudsman found it was fair for Wakam to rely on the exclusion because Miss D was aware of the issues affecting the dog, had reported them to the vet, and investigation and treatment had already taken place, so she could not reasonably have thought further investigation would not be required.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website