Not upheld: claim decline and misrepresentation; pre-existing condition exclusion complaint against Casualty & General Insurance Company (Europe) Ltd

Decision detail

Summary

Mr A complained that Casualty & General Insurance Company declined his pet insurance claim and added an exclusion to his policy. Mr A had taken out pet insurance for his dog in May 2024 and made a claim for treatment in September 2024. The insurer declined the claim citing pre-existing condition and misrepresentation, as Mr A had answered 'No' to a question about pre-existing conditions despite clinical records showing his dog had a longstanding regurgitation problem requiring special feeding since at least October 2020. The ombudsman found Mr A failed to take reasonable care in answering the question, as he knew his dog had an ongoing condition that needed management, even though the formal diagnosis (GERD) came later. The ombudsman upheld the insurer's decision to add the exclusion and decline the claim as a fair application of CIDRA and the policy terms.

The Ombudsman's reasoning

The ombudsman found the insurance question was clear and that Mr A failed to take reasonable care by not disclosing his dog's longstanding regurgitation problem, which he knew about and had to manage through special feeding practices. Although the formal diagnosis came later, Mr A knew something was wrong with his dog's condition well before the policy started. This constituted a qualifying misrepresentation under CIDRA, allowing the insurer to add exclusions on amended terms. Additionally, the condition was pre-existing as it existed when the policy started and Mr A knew or should have known about it, making it uninsurable under the policy terms.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website