Upheld: wrongful claim denial; incorrect application of pre-existing condition exclusion complaint against Great Lakes Insurance SE

Decision detail

Summary

Ms G claimed on her pet insurance policy for treatment costs for her cat T's cat flu and associated dental treatment. Great Lakes declined the claims, arguing that T had shown signs of cat flu prior to the policy commencing in November 2022 and therefore the condition fell within the pre-existing condition exclusion. The ombudsman reviewed the veterinary evidence and found that while T displayed some respiratory symptoms in September 2022, these could equally indicate a different infection, and critically, the notes recorded no fever, which is a common symptom of cat flu. Cat flu was not diagnosed until February 2023, after the policy commenced. The ombudsman concluded that Great Lakes failed to demonstrate on balance that the pre-inception symptoms were caused by the same condition as the subsequent claim, and therefore the pre-existing condition exclusion did not apply. The complaint was upheld and Great Lakes was ordered to settle the claims and pay £100 compensation.

The Ombudsman's reasoning

The ombudsman applied the principle that where an insurer seeks to rely on a policy exclusion to decline a claim, the onus is on the insurer to show the exclusion applies. For the pre-existing condition exclusion to apply, Great Lakes needed to demonstrate on balance that the symptoms T displayed prior to policy inception were caused by the same condition (cat flu caused by feline calicivirus) that led to the subsequent claim. While some pre-inception symptoms (sneezing, coughing, discharge) could correlate with cat flu, they could equally indicate a different respiratory infection. Critically, the pre-inception notes specifically recorded no fever, which is a common symptom of cat flu. The vet did not confirm a link between pre-inception issues and the diagnosed cat flu. Different medications were prescribed pre and post-inception, which does not support Great Lakes' position. Although cat flu can be chronic and could theoretically have been present pre-inception, Great Lakes failed to demonstrate this was most likely the case based on the available evidence.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website