Upheld: unfair claim decline / misapplication of policy terms complaint against Pinnacle Insurance Limited
Financial Ombudsman decision DRN-6404264 of 2026-06-04T00:00:00+00:00. unfair claim decline / misapplication of policy terms complaint against Pinnacle Insurance Limited. Outcome: Upheld.
Decision detail
| Reference | DRN-6404264 |
|---|---|
| Decision date | 2026-06-04T00:00:00+00:00 |
| Firm | Pinnacle Insurance Limited |
| Product | Other regulated product |
| Claim type | unfair claim decline / misapplication of policy terms |
| Outcome | Upheld |
| Remedy | Pinnacle Insurance Limited must: (1) pay the May 2025 claims for MPL treatment and any other vet fees incurred for this condition since, plus 8% simple interest per annum from the date Mrs C paid the vet until reimbursement; (2) cover ongoing treatment costs for MPL up to the policy's maximum benefit limit of £4,000 (with £3,284.15 remaining after the £715.85 already paid); (3) pay £200 compensation for distress and inconvenience. |
Summary
Mrs C claimed for veterinary treatment of her dog's Medial Patellar Luxation (MPL) in the right hindlimb under her pet insurance policy with Pinnacle. Pinnacle initially accepted and paid for MPL treatment but later declined further claims, arguing the MPL was linked to a CCL rupture in the left leg from three years earlier, meaning the policy's £4,000 per-condition limit had been exhausted. The treating vet consistently stated the conditions were separate, but Pinnacle relied on independent veterinary advice obtained only after the complaint was escalated to the FOS. The ombudsman found the conditions were not sufficiently linked on the balance of probabilities and upheld the complaint, directing Pinnacle to pay outstanding claims, cover ongoing MPL treatment, and pay £200 compensation.
The Ombudsman's reasoning
The ombudsman found that while the independent vet's opinion suggested CCL ruptures can cause MPL, this was general advice not specifically evidenced in this dog's clinical notes. The treating vet consistently diagnosed MPL as a separate condition and stated any CCL movement in the right leg was secondary to the MPL, not caused by the left leg's CCL rupture from three years prior. The ombudsman noted that CCL-caused MPL typically occurs in the same leg around the same time, which was not the case here. Pinnacle's decision to decline claims was made without supporting evidence and only after the complaint was raised. The ombudsman concluded the conditions were not sufficiently linked to be treated as one condition under the policy.
How this compares
| Group | Decisions | Uphold rate |
|---|---|---|
| Pinnacle Insurance Limited, all decisions | 32 | 14% |
| Other regulated product, all decisions | 52,408 | 30% |
Source
Read the original decision on the Financial Ombudsman Service website