Not upheld: claim declined - pre-existing condition exclusion complaint against Wakam

Decision detail

Summary

Ms B claimed on her Wakam pet insurance policy for behavioural treatment for her rescued pet's generalised fear and anxiety disorder. Wakam declined the claim as a pre-existing condition, arguing symptoms were present during the waiting period. Ms B contended the condition was not pre-existing as the pet was only formally diagnosed two months after the policy started. The ombudsman reviewed clinical evidence and found the pet exhibited consistent symptoms of fear and anxiety from the date the policy was taken out, satisfying the policy's definition of pre-existing conditions. The ombudsman upheld Wakam's decision to decline the claim as the symptoms fell within the waiting period exclusion.

The Ombudsman's reasoning

The ombudsman found that although the pet was formally diagnosed two months after the policy started, clinical evidence clearly demonstrated the pet was exhibiting the same symptoms of fear and anxiety from the date the policy was taken out and throughout the waiting period. The policy terms explicitly exclude any illness showing signs or symptoms during the waiting period, regardless of when a formal diagnosis is made. The timing of clinical documentation does not change the fact that symptoms were present from inception.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website