Partially upheld: unfair claim decline and retrospective policy exclusion complaint against Red Sands Insurance Company (Europe) Limited

Decision detail

Summary

Mrs W complained that Red Sands Insurance unfairly declined a claim for her dog's ear treatment and added a retrospective exclusion. The dog was examined in September 2024 with swollen ears diagnosed as chronic otitis, before the policy was taken out in February 2025. The ombudsman found the claim decline was fair because the condition was pre-existing and Mrs W was aware of the problem. However, the retrospective exclusion was unfairly applied because Mrs W was not asked a clear and specific question about pre-existing conditions when taking out the policy, contrary to CIDRA requirements. The ombudsman directed Red Sands to remove the retrospective exclusion.

The Ombudsman's reasoning

The ombudsman found that Red Sands fairly declined the claim because: (1) the condition was pre-existing, as signs and symptoms were present before policy inception in September 2024; (2) the veterinary evidence showed allergies/atopy as a common theme directly connected to the ear condition; and (3) Mrs W was aware something was wrong with her dog when she took it to the vet before policy inception. However, the retrospective exclusion was unfairly applied because CIDRA requires clear and specific questions to be asked about pre-existing conditions at the point of sale, and the phone call recording showed Mrs W was not asked such a question. Therefore, she could not have made a misrepresentation.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website