Not upheld: claim decline - policy limit exhaustion complaint against UK Insurance Limited trading as Direct Line Pet Insurance

Decision detail

Summary

Mr M complained that UKI unfairly declined his pet insurance claim for treatment of mast cell tumours on his pet's body. UKI had previously paid a claim for mast cell tumours on the pet's nose in 2021 under a time-limited Essential cover policy providing 12 months of cover per condition. When Mr M claimed for tumours on a different body part, UKI declined the claim as the 12-month limit had been exhausted. The ombudsman found the decline was justified because the policy terms treat tumours with the same diagnosis as a single condition regardless of location, and UKI had notified Mr M in 2021 that cover for this condition would end in October 2022. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman applied the policy terms which define tumours with the same diagnosis as a single condition subject to the same policy limit, regardless of body location or timing. Although the tumours were separate in time and location, they were the same type caused by the same disease process and therefore constituted one condition under the policy. UKI had already exhausted the 12-month limit for this condition following the 2021 claim and had notified Mr M of the cover end date. The ombudsman concluded UKI acted entirely in line with the policy terms and that it is not the FOS's role to dictate what types of cover insurers may offer.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website