Not upheld: claim decline based on pre-existing condition exclusion complaint against Covea Insurance plc

Decision detail

Summary

Mr S claimed on his pet insurance policy for treatment costs (£4,404) incurred when his rabbit M underwent investigation and molar extraction for gut stasis in March 2025. Covea declined the claim citing the pre-existing condition exclusion, arguing that M had experienced gut stasis episodes before the June 2024 policy inception and had pre-existing dental issues. The treating vet argued the March 2025 episode was caused by new conditions: tooth root abscessation and abdominal adhesions, distinct from M's previous dental disease and stress-related stasis. The ombudsman found that while the vet's evidence was usually persuasive, the CT scan report contradicted the abscessation diagnosis and the evidence suggested both potential causes were more likely than not pre-existing or related to pre-policy conditions. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman applied the policy definition of pre-existing conditions, which includes conditions that first showed clinical signs before cover started, or are the same as/related to/caused by conditions that existed before cover started. The ombudsman found that while gut stasis is a symptom rather than a diagnosis, the underlying causes identified in March 2025 (adhesions and dental disease) were more likely than not pre-existing. Regarding adhesions: the CT scan was unclear on diagnosis, but if present, they would likely have formed following the 2023 surgery or previous gut stasis episodes, making it probable they contributed to earlier unexplained stasis episodes before June 2024. Regarding dental disease: the CT scan contradicted the vet's assertion of tooth root infection (reporting no evidence of abscessation), and the dental disease found was consistent with M's pre-policy history of routine dental issues. The loose molar identified in January 2024 was the same tooth removed in March 2025, suggesting continuity of the dental problem rather than a new condition.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website