Upheld: unfair claim decline - misapplication of pre-existing condition exclusion complaint against Covea Insurance plc
Financial Ombudsman decision DRN-6115359 of 2026-06-12T00:00:00+00:00. unfair claim decline - misapplication of pre-existing condition exclusion complaint against Covea Insurance plc. Outcome: Upheld.
Decision detail
| Reference | DRN-6115359 |
|---|---|
| Decision date | 2026-06-12T00:00:00+00:00 |
| Firm | Covea Insurance plc |
| Product | Other regulated product |
| Claim type | unfair claim decline - misapplication of pre-existing condition exclusion |
| Outcome | Upheld |
| Remedy | Covea Insurance plc must: (1) pay the claim in line with the remaining policy terms and conditions together with interest at 8% simple per annum from the date Mr F paid for treatment until settlement; (2) pay £100 for distress and inconvenience caused to Mr F. Payment must be made within 28 days of Mr F's acceptance of the decision, with additional interest at 8% per annum simple if payment is delayed. |
Summary
Mr F claimed on his pet insurance policy for treatment of a trichoepithelioma on his dog's face in July 2025. Covea declined the claim as a pre-existing condition, citing that the dog had been treated for a trichoepithelioma on its back in 2021 before the policy commenced. Although both lumps had the same diagnosis, the ombudsman upheld the complaint, finding that Covea had not adequately demonstrated the two lumps were directly connected or had the same underlying cause. The four-year gap between incidences and veterinary evidence that trichoepitheliomas do not spread to distant sites persuaded the ombudsman that the claim should be paid. Covea was directed to pay the claim with 8% interest and £100 compensation for distress and inconvenience.
The Ombudsman's reasoning
While the policy terms could be applied strictly to capture the claim due to identical diagnosis, the ombudsman considered what was fair and reasonable in the circumstances. The four-year gap between occurrences and the persuasive professional veterinary evidence that trichoepitheliomas do not spread to distant sites meant Covea had not adequately demonstrated the two lumps were directly connected or had the same underlying cause. The ombudsman placed significant evidential weight on the veterinary professional's opinion and found Covea had not presented opposing medical evidence to rebut it.
How this compares
| Group | Decisions | Uphold rate |
|---|---|---|
| Covea Insurance plc, all decisions | 1,259 | 38% |
| Other regulated product, all decisions | 52,408 | 30% |
Source
Read the original decision on the Financial Ombudsman Service website