Not upheld: claim declined - pre-existing condition exclusion complaint against Antares Insurance Company Limited

Decision detail

Summary

Mr T claimed reimbursement from Antares Insurance Company Limited for surgery to remove a lump from his dog's eyelid. Antares declined the claim on the basis that the lump was a pre-existing condition, as veterinary notes from March 2023 and March 2024 (before the April 2025 policy start date) documented its presence. Mr T argued the earlier note recorded only a symptom that had resolved and required no ongoing treatment, and that the insurer was retrospectively interpreting the notes with hindsight. The ombudsman found that the policy terms clearly excluded pre-existing conditions and that the lump was directly relevant to the claim, as it caused the eye irritation requiring treatment. The complaint was not upheld, with the ombudsman finding Antares had fairly applied the policy exclusion.

The Ombudsman's reasoning

The ombudsman found that the policy terms clearly exclude cover for pre-existing conditions, defined as any health problem or undiagnosed condition existing before the policy start date. The veterinary evidence showed the lump was present over two years before the policy commenced and Mr T was advised to monitor it. Although the lump itself was a symptom rather than a diagnosis, the policy term covers any health problem the pet has before the policy starts, and the lump directly caused the need for treatment. The ombudsman rejected the argument that the symptom had resolved, noting that Mr T's previous experience with other lumps requiring removal and one being diagnosed as cancer would have made him aware of the importance of monitoring such masses. The ombudsman also found that Antares was not obliged to pre-authorise the claim as this is not part of standard pet insurer processes.

How this compares

Source

Read the original decision on the Financial Ombudsman Service website