This note explains our approach to complaints about pet insurance policies.
Pet insurance is designed to help consumers pay for unexpected veterinary bills and related treatment. The policies may also provide other pet-related benefits including:
Pet insurance policies are very popular but – like most insurance policies – they do not provide cover in every situation. A policy might include restrictions that may not be immediately obvious to the consumer.
There are two main types of pet insurance policy: annual policies and lifelong policies.
Annual policies are the most common type of pet insurance policy. They cover conditions that arise within the policy term – which is usually 12 months.
When an annual policy is renewed, a condition the consumer has claimed for in the previous 12 months may still be covered by the new policy – if the time or money limit specified in the old policy has not been reached.
However, if the limit has been reached – or the insurer decides not to renew cover for the condition – then the consumer will have to pay for any further costs relating to that condition.
This type of policy provides continuous cover for ongoing conditions throughout the pet’s lifetime (so long as the policy is renewed periodically.)
So if a claim is made for a particular condition in the first year, the consumer may be able to claim for that same condition in later years. The insurer cannot usually amend the basic cover provided by the policy.
There is more information about pet insurance policies, including a consumer guide, available on the ABI's website.
The complaints we see usually arise when an insurer refuses to pay a claim. This may happen when the insurer says that:
When we consider a case, we look at the policy wording and any other relevant documentation, including the policy summary. We take into account any medical evidence provided by vets – particularly clinical notes and written submissions.
Most pet insurance policies contain similar exclusions and limitations. But if we decide that the policy in question contains any that are significant and unusual, we will consider whether the business made the consumer aware of them – and their effect – when the policy was taken out.
We also look at whether an insurer's interpretation of key words in the policy conditions was reasonable.
When refusing to pay a claim, an insurer might make specific reference to the meaning of certain key words in the policy – such as ”condition” or ”treatment”.
Some policies provide a glossary of key words. Where an insurer defines a term differently from its everyday meaning, we will consider whether this was made clear and brought to the consumer’s attention.
We sometimes see definitions that are ambiguous and unclear – meaning they could have a wider scope than the insurer intended. Here, we may decide that an exclusion or limitation has been applied in an unfair way.
For example, examinations or consultations are not generally considered to be “treatments”. So if they were included in the policy definition of “treatment”, we would check that this had been brought to the consumer’s attention.
Most pet insurance policies do not provide cover for pre-existing conditions. If an insurer declines a claim on the grounds that the pet already had the condition before the policy was taken out, we will look at how much the consumer actually knew when taking out the policy.
We might say that it was reasonable for an insurer to reject a claim if we think that the consumer knew about the condition when taking out the policy. Or where the policy excludes pre-existing symptoms as well as conditions, we will decide if we think the consumer knew about any symptoms that raised a clear possibility of a future claim.
There is more information about our general approach to complaints involving pre-existing conditions in our online technical resource.
Pet insurance policies do not usually cover conditions that arise within the first few days of the policy. Although we are unlikely to say that this is unfair, it is significant – so we will consider whether it was brought to the consumer’s attention.
Sometimes, we find the insurer just told the consumer to read the policy document at when the policy was sold. Even though this would have mentioned that cover did not begin immediately, we are unlikely to agree that the insurer sufficiently brought this fact to the consumer’s attention in this situation.
Where we see evidence that the issue was brought to the consumer’s attention – perhaps by giving them a factsheet – we may agree it was reasonable for an insurer to refuse to pay a claim. But this will only be the case if we think the consumer knew about the condition or any signs or symptoms that should have alerted them that there was a problem.
Sometimes, a consumer takes their pet to a vet with signs of a condition in the first few days after a policy starts. An insurer may reject a later claim for the condition, saying the consumer was aware of it at this early stage. Here, we would consider what the vet told the consumer. If we find that the consumer that was told there was no problem and that no treatment was necessary, we are unlikely to agree with the insurer’s decision.
Pet insurance policies often limit cover for a particular condition to 12 months from the date of the first treatment for it. Some policies cover 12 months of treatment from the date of a claim.
Because it is rare for a condition to arise on the exact date that a policy is taken out, the consumer may find that they are unable to claim for the full 12 months if they do not renew the policy. Consumers sometimes say this is unfair because to gain the full benefit of the 12 months’ cover, they have to renew with the same insurer for another year.
When looking at complaints of this type, we consider whether we think long-term treatment was foreseeable. If a vet has told the consumer that treatment is likely to be ongoing for several months, and this period would go beyond the term of the policy, we may say that the insurer should pay the claim for the full 12 months after the first treatment – even if the policy was not renewed.
However, it is unlikely that we would uphold a complaint about an insurer not paying a claim when the policy term had already ended if:
When an insurer settles a claim, it usually tells the consumer that any future claims for the same condition will not be covered after another 12 months have passed. This helps the consumer make an informed decision about whether to renew the policy after the 12 months of cover for that condition has expired.
If we find that the insurer did not highlight the time limit, we will consider whether the consumer would have continued to insure the pet if they had known that cover for a particular condition had run out.
Where we think that it is likely the consumer would not have renewed the policy, we may tell the insurer to refund all the premiums (plus interest) that the consumer paid after renewing.
In some cases, we think that the consumer would have opted to have their pet treated sooner if they had they known about the time limit. Or we see evidence that the consumer was told when the policy was renewed that cover for the condition would continue.
In both these situations, we may tell the insurer (or the seller of the policy) to pay the cost of treatment.
Some conditions in pets can to occur on both sides of the animal – for example, hip dysplasia. These are known as ”bi-lateral” conditions.
If a condition has previously affected one side of a pet and the consumer then makes a claim for the other side, insurers sometimes say that:
If we are satisfied that the same underlying issue has caused the condition, we are likely to agree that it was reasonable for an insurer to reject the claim. In particular, we will assess whether we think the consumer knew that it was likely the second side would later be affected.
For example, a consumer might complain that an insurer rejected a claim for a condition in their dog’s left hip, which had occurred in the right hip first 15 months previously.
If we find that the underlying issue was the same – and that the consumer had been aware of signs of the condition in the second hip for some time – we are likely to agree with the insurer’s decision to reject the claim.
However, if we are satisfied that the two occurrences of the condition are not connected – even if the condition is the same – we may say they should be treated as separate claims.
We are unlikely to agree if the insurer says that because the condition is often “bi-lateral”, then the second claim is outside of the time limit and should be rejected.
If the condition can have different symptoms and manifestations – despite coming under one “umbrella” name – we will look at the available evidence, including the vet’s opinion, to decide if the two occurrences were directly connected.
In some cases, the consumer complains that an insurer has substantially increased the premiums when renewing the policy.
Insurers take into account a variety of factors in deciding the premium for a policy, including previous claims, or the pet’s age and breed – which affect how likely someone is to make a claim. And insurers will also take into account general factors like the total number of claims made by their customers overall.
Generally, it’s not for us to tell an insurer what it should charge for covering a particular risk. But we can look at whether a policyholder has been treated fairly and reasonably in the way their premium was worked out and applied. That’ll often involve asking for underwriting criteria and a breakdown of those factors which caused the price to go up.
If we find that there was a justifiable increase for all similar consumers, we might explain that this isn’t unfair. But if we think that the insurer increased the premium to unfairly profit from their customer – or deter them from renewing – we are likely to uphold the complaint.
Equine policies often provide cover in the event of a horse having to be put down. However, most policies contain a condition or exclusion saying that a claim is not covered unless the decision to put the horse down is in line with the British Equine Veterinary Association (BEVA) guide to best practice when considering euthanasia on humane grounds.
Paragraph 3 of the BEVA 1996 guidelines says that for a claim to be paid it must be shown that:
... the insured horse sustains an injury or manifests an illness or disease that is so severe as to warrant immediate destruction to relieve incurable and excessive pain and that no other options of treatment are available to that horse at that time.
If immediate destruction cannot be justified then the attending veterinary surgeon should provide effective first aid treatment before:
1. requesting that the insurance company be contacted or, failing that
2. arrange for a second opinion from another veterinary surgeon.
Some equine policies say specifically that the BEVA guidelines must be complied with for a claim to be paid. But some policies use a different wording – for example:
We will not pay any amount if your vet or our vet believes the illness or injury your horse is suffering from can be treated.
This section does not insure:
Any amount if the euthanasia was carried out without our consent unless a veterinary surgeon certifies that the suffering is incurable and is so excessive that immediate euthanasia is imperative for humane reasons.
If we see enough evidence that no alternative treatment was available – and that it was necessary to put the horse down – we are likely to uphold a complaint about an insurer’s refusal to pay a claim.
Our general approach to lifetime pet insurance policies is set out in an ombudsman's final decision partly upholding a consumer's complaint about Halifax's withdrawal from "lifetime" pet insurance. This followed an earlier provisional decision.
This is part of our online technical resource which sets out our general approach to complaints about a wide range of financial products and issues. We would like your feedback on how helpful you found it. Please also use the feedback form below to tell us about anything you think we could clarify or explain better.