Not upheld: claim declined - causation dispute complaint against HDI Global Specialty SE

Decision detail

Summary

Mr P claimed on his pet insurance policy with HDI for dental treatment, which HDI declined. The policy only covered dental treatment for accident, not illness. Mr P argued the treatment was for an accident after his pet's tooth fell out from hitting something. However, the veterinary clinical notes and the treating vet's evidence established that the dental extractions were due to dental disease (resorptive lesions/FORLs), not trauma. The vet confirmed there was no known link between trauma and FORLs. The ombudsman found HDI fairly declined the claim as the treatment was for illness, not the covered cause of accident.

The Ombudsman's reasoning

The ombudsman found that the contemporaneous veterinary clinical notes were the strongest evidence and clearly established that the dental extractions were due to dental disease (resorption), not trauma. Although the pet may have experienced an earlier injury causing tooth loss, this did not support that the claimed treatment was for that injury. The treating vet's subsequent evidence confirmed the treatment was not for injury or trauma, and stated there is no known link between trauma and FORLs. Therefore, HDI fairly declined the claim as it fell outside the policy's coverage for accident-only dental treatment.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website