Not upheld: claim decline and policy cancellation complaint against Red Sands Insurance Company (Europe) Limited

Decision detail

Summary

Mrs H claimed on her pet insurance policy for her cat's treatment following an apparent head injury. Red Sands declined the claim on the basis that the treatment was dental in nature and the policy explicitly excluded dental treatment. Mrs H complained about the claim decision and the service received, and subsequently complained about the policy cancellation. The ombudsman found the policy terms clearly excluded dental treatment, this exclusion was prominently displayed in the IPID, and the clinical records confirmed the treatment was primarily dental involving multiple extractions and treatment for gingivitis. The ombudsman concluded Red Sands dealt with the claim fairly and that the policy was cancelled at Mrs H's request, not by Red Sands' choice.

The Ombudsman's reasoning

The ombudsman applied the principle that insurance policies are subject to terms and conditions that limit the insurer's liabilities, and it is for the insurer to decide which risks to cover. The policy terms clearly and explicitly excluded dental treatment, and this exclusion was prominently featured in the IPID. The clinical records demonstrated that the treatment was primarily dental in nature, involving multiple extractions and treatment for gingivitis, with only one tooth potentially affected by trauma. Even if trauma caused one tooth's damage, the widespread dental treatment meant the claim fell within the excluded category. The call handler's response was reasonable given the information provided at that time. The policy cancellation was initiated by Mrs H herself in response to the declined claim, not by Red Sands.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website