Upheld: unfair claim decline - pre-existing condition exclusion complaint against Covea Insurance plc

Decision detail

Summary

Mr M complained that Covea Insurance plc unfairly declined his pet insurance claim for surgery to remove a lipoma in July 2025, citing a pre-existing condition exclusion because lipomas had been noted in June 2020 and April 2022. The ombudsman upheld the complaint, finding that although the policy terms define pre-existing conditions broadly, it would be unfair to apply the exclusion strictly in these circumstances. The clinical evidence showed the earlier lipomas did not require removal, there was a significant gap in documentation, and the lipoma requiring surgery only appeared in 2025, meaning Mr M could not reasonably have known at the point of purchase that his dog would need treatment. Covea was directed to settle the claim, pay interest, and pay £150 compensation for distress and inconvenience.

The Ombudsman's reasoning

The ombudsman applied the principle that while the policy terms define a pre-existing condition broadly to include any manifestation of an illness with the same diagnostic classification, it is fair to apply this exclusion strictly only where the policyholder knew or should reasonably have known when buying the policy that something was wrong and likely to lead to investigation or treatment. The key distinction is whether the earlier lipomas were active issues requiring monitoring or treatment. The clinical evidence showed the earlier lipomas did not require removal, there was a significant gap in documentation, and the lipoma requiring surgery only appeared in 2025. Therefore, Mr M could not reasonably have known at the point of purchase that his dog would need treatment for lipomas.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website