Not upheld: claim decline - related conditions complaint against Red Sands Insurance Company (Europe) Limited

Decision detail

Summary

Mr V complained that Red Sands Insurance Company (Europe) Limited unfairly declined a claim for emergency surgery on his dog on 6 February 2026, arguing it was for a separate condition (generalised small intestinal ileus) from the chronic enteropathy treated on 3 February 2026. Red Sands declined the second claim as a continuation of the first condition, which had exhausted the £2,000 annual condition limit. The ombudsman found that the veterinary evidence, including expert opinion from the treating hospital's internal medicine team, established that ileus was connected to and commonly caused by the underlying chronic enteropathy. On the balance of probabilities, considering the three-day timescale, similar symptoms, and expert veterinary opinion, the ombudsman concluded these were one condition under the policy terms, not two separate conditions. The complaint was not upheld.

The Ombudsman's reasoning

The ombudsman applied the policy definition of 'condition' as any injury or illness with a single cause or diagnosis. The ombudsman found that the veterinary evidence, including expert opinion from the treating hospital's internal medicine team, established that chronic enteropathy and ileus were connected conditions, with ileus commonly resulting from gastrointestinal inflammation. On the balance of probabilities, given the three-day timescale, similar symptoms affecting the same body area, and veterinary advice that one condition commonly leads to the other, the ombudsman concluded these were one condition under the policy terms, not two separate conditions.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website