Not upheld: claim declined - pre-existing condition exclusion complaint against Pinnacle Insurance Limited

Decision detail

Summary

Mr P claimed on his Pinnacle pet insurance policy for an abscess on his pet's neck less than a month after taking out cover in May 2025. Pinnacle declined the claim as a pre-existing condition, arguing it was related to a lump the pet had been treated for in 2020 and subsequently in 2023. Mr P disputed this, claiming the 2025 problem was unrelated and involved a different foreign body. The ombudsman reviewed the clinical notes and found the lump had persisted in the same location since 2020 despite treatment, and that the abscess likely presented before the policy's two-week waiting period ended. The ombudsman upheld Pinnacle's decision to decline the claim and did not uphold Mr P's complaint.

The Ombudsman's reasoning

The ombudsman applied the policy terms which exclude pre-existing conditions and injuries or illnesses the pet had before the policy start date. The clinical notes showed the lump had persisted since 2020 despite treatment, was noted in 2023 and 2024, and the current problem was in the same location. The ombudsman found it more likely than not that the abscess had presented before the two-week waiting period ended, supported by the CT report showing an 8-month history. Even if the claim were unconnected to earlier problems, cover would not have engaged because the abscess was presenting before Mr P took out insurance.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website