Not upheld: unfair application of policy exclusions and claim decline based on non-disclosure complaint against Allianz Insurance Plc trading as Petplan

Decision detail

Summary

Mr V complained that Allianz unfairly added retrospective exclusions to his pet insurance policy and declined a claim for his cat's treatment. Allianz had initially paid the claim but later discovered the cat had previous vet treatment for gastrointestinal and eye issues that Mr V had not disclosed when taking out the policy. The ombudsman found that Mr V's answers to clear disclosure questions were inaccurate and constituted a qualifying misrepresentation under CIDRA. Allianz's underwriting guide confirmed that accurate disclosure would have resulted in exclusions being added from inception. The ombudsman upheld Allianz's position that the exclusions were fairly applied and the claim decline was justified, though found Allianz's decision not to recover the claim payment was reasonable.

The Ombudsman's reasoning

The ombudsman applied CIDRA to determine whether there was a qualifying misrepresentation. The questions asked were clear and not misleading. Mr V's answers of 'No' were inaccurate given the documented medical history, constituting a failure to take reasonable care. Allianz's underwriting guide confirmed that accurate disclosure would have resulted in exclusions being added from inception, making this a qualifying misrepresentation. Treating it as careless rather than deliberate/reckless was reasonable. Therefore, the retrospective exclusions were fairly applied and the claim decline was justified.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website