Not upheld: unfair claim decline - pre-existing condition exclusion complaint against Pinnacle Insurance Limited

Decision detail

Summary

Ms S claimed on her pet insurance policy with Pinnacle for her dog's patella luxation treatment following a July 2025 diagnosis and recommendation for surgery. Pinnacle declined the claim citing the pre-existing condition exclusion, noting that the dog's medical history showed discussions about patella luxation symptoms as early as June 2024, before the policy was taken out on 6 August 2024. Ms S argued the condition was not diagnosed until July 2025. The ombudsman upheld Pinnacle's decision, finding that the policy exclusion covers signs or symptoms of undiagnosed illnesses, and the medical evidence clearly demonstrated the dog exhibited symptoms before the policy start date with Ms S's awareness.

The Ombudsman's reasoning

The ombudsman applied the standard test for pre-existing condition exclusions, requiring satisfaction that: (1) the condition claimed for is the same or directly connected to an illness present before policy start, and (2) the policyholder was aware something was wrong with their pet at policy inception. The policy exclusion covers signs or symptoms of undiagnosed illnesses, not just diagnosed conditions. The medical evidence clearly showed symptoms of patella luxation were present and discussed before 6 August 2024, and Ms S was aware of these issues through her vet discussions. Therefore, Pinnacle fairly applied the exclusion.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website