Not upheld: Travel / life insurance claim disputes complaint against Wakam

Decision detail

Summary

Mr C complained that Wakam unfairly declined his pet insurance claim for respiratory problems. Mr C had initially taken out cover on 3 January 2025 and upgraded it on 27 January 2025, which created a new policy starting on 27 January 2025. He made a claim in April 2025 for investigation of respiratory problems. Wakam declined the claim as pre-existing because vet clinical notes from 17 January 2025 documented that the pet was presenting with respiratory concerns and further investigations were recommended before the new policy commenced. The ombudsman found the claim was correctly declined under the policy's pre-existing condition exclusion, as the pet was exhibiting signs or symptoms before cover started and Mr C ought to have reasonably been aware of this. The ombudsman also found Wakam provided appropriate advice about pre-existing conditions during the upgrade call and that the £275 compensation offered for processing delays was adequate.

The Ombudsman's reasoning

The ombudsman applied the policy definition of pre-existing conditions, which excludes any medical condition that showed signs or symptoms in the 24 months before the plan starts. The clinical notes from 17 January 2025 clearly documented that the pet was presenting with respiratory problems and further investigations were recommended. This was sufficient to establish that Mr C ought to have reasonably been aware there was a problem requiring further investigation before the new policy commenced on 27 January 2025. Even if the old policy terms had applied, the condition would still have been excluded as it displayed signs within the 14-day waiting period. Wakam provided appropriate advice about pre-existing conditions during the upgrade call.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website