Pet insurance

What we look at

• Complaints about the policy wording

  When rejecting a claim by using an exclusion or limitation, you might refer to the meaning of certain key words in the policy; for example, ‘condition’ or ‘treatment’. If you’ve defined a term differently from its everyday meaning, we’ll look at how you did this in the policy. For example, was there a key words glossary? We’ll also consider how you explained this to the customer.

  If there are vague definitions that could have a wider scope or a meaning other than you intended, we may decide that you’ve unfairly applied the exclusion or limitation. For example, an examination or consultation isn’t generally considered to be a ‘treatment’. So we’d look at how the policy defines ‘treatment’ and whether you brought this to the customer’s attention.

• Complaints involving something affecting the animal before the policy was taken out

  We see complaints from customers who have had a claim rejected because:

  • the animal already suffered from the condition when the policy was taken out
  • the animal first showed signs of the condition shortly after the policy was taken out, and the policy didn’t cover conditions arising so soon
  • the customer didn’t disclose significant information about the pet's medical history

  Most policies don’t cover pre-existing conditions. If we think your customer knew about the condition when they took out the policy, we might agree that it’s reasonable for you to reject the claim.

  If you’ve rejected a claim because of pre-existing symptoms, we’ll check whether this exclusion was clearly explained in the policy document. We’ll decide whether the customer knew about any symptoms that could lead to a condition being claimed for in the future.

  Conditions that first became apparent soon after the policy was taken out

  A customer might take their pet to a vet with signs of a condition in the first few days after a policy starts. You may reject a later claim for that condition, saying the customer was already aware of it.

  Policies don’t normally cover conditions that appear within the first few days after the start date. Although we’re unlikely to say this is unfair, it is significant – so we’ll look at what you did to make sure your customer was aware.

  We wouldn’t agree that it was enough to tell the customer to read the policy document.

  But we may say it was reasonable for you to reject the claim if we find evidence that your customer was aware of the term or exclusion.
  We’ll also look at what the vet said about the condition. If they said there was no problem and no treatment was necessary, we’re likely to uphold the complaint.

• Time limits on cover for treatment

  We see complaints where a customer is claiming for treatment that took place more than 12 months after the condition first appeared, but their cover only lasted for 12 months after the first sign of the condition.

  Some policies may limit cover for a particular condition to 12 months from the date of the first treatment. Other policies may cover 12 months of treatment from the date of a claim.

  We’ll look at what the policy says, but we’d normally say it’s fair for an insurer to start the 12 months from when the customer could have made a claim. This is usually when a vet recommends some sort of investigation or treatment for clinical signs of a condition. If the vet recommends an investigation or treatment, but the consumer decides not to go ahead with it, we’d still usually say the 12 month period had begun.

  It’s rare for a condition to appear on the exact date that a policy starts. So the policyholder will normally have to renew the policy to be able to claim for the full 12 months.

  If an insurer rejects a claim because the policy term had ended, we’re unlikely to uphold the complaint if we think the document made it clear that cover stopped at the end of the annual policy. We wouldn’t usually ask an insurer to pay for claims if the policy had ended and the customer was no longer paying the premiums.

  Telling customers about the 12-month limit

  When settling a claim, insurers usually tell customers that any future claims for the same condition won’t be covered after another 12 months have passed. This helps the customer make an informed decision about whether or not to renew the policy once the year of cover for that particular condition has expired.
  
  If you didn’t highlight this time limit, we’ll consider whether your customer would have continued with the policy.
  
  In some cases, we may think customers would have had their pets treated sooner if they’d known about the time limit. We’ve also seen cases where a customer has been told that cover for the condition would continue when the policy was renewed.

  In both these situations, we’re likely to tell you to pay the cost of treatment.

  Lifetime policies

  Lifetime policies provide continuous cover for ongoing conditions throughout a pet’s life. If an insurer describes a policy as ‘lifelong’ or ‘lifetime’, they wouldn’t normally be able to change the policy’s basic cover.

  If an underwriter withdraws cover, and the customer isn’t offered an option to renew, they will effectively have lost their lifetime cover – and it’s unlikely a new insurer will cover any existing conditions. If the customer takes out a new lifetime policy with another insurer, we’re likely to tell you to provide ongoing cover for any existing conditions that aren’t covered by the new policy.

  Read an example of our approach when a customer couldn’t find alternative cover when her policy was withdrawn from the market (PDF 24KB). 

  If the customer is offered a new policy with a different underwriter, it’s likely we’ll say the new policy should reflect the old policy’s terms and conditions. This should include any conditions that would have been covered by that policy.

  Read an example of our approach when a customer found that his level of cover wasn’t the same when his underwriter was changed (PDF 17KB). 

  In both situations, we may award compensation for any distress and inconvenience.

  We also see complaints where an insurer makes changes to a lifetime policy at renewal. Insurers can make changes, but if these significantly change the customer’s original cover, we’re likely to uphold the complaint.

• Bilateral conditions

  Some conditions can occur on both sides of the animal’s body at different times – for example, hip dysplasia. These are known as ‘bilateral’ conditions.

  We see complaints where a pet has a bilateral condition, but the insurer won’t regard the second problem as a separate condition. So if a condition has previously affected one side of an animal and your customer then claims for the other side, you might reject the claim because:

  • there was a pre-existing condition
  • the 12-month time limit began when the problem occurred on the first side and has now expired

  We’ll look for evidence that the customer knew that the second side was likely to later become affected. For example, someone might complain that you rejected a claim for a condition in their dog’s left hip, which had first occurred in the right hip 15 months previously.

  If we think the same underlying issue has caused the condition, we’re likely to agree that it was reasonable for you to reject the claim.
  
  However, if we think the two events aren’t connected, we might tell you to treat them as separate claims – even if the condition is the same.

  We’ll look at the available evidence, such as the vet’s opinion, to decide if the two events were directly connected.

• Complaints about increased premiums

  A customer may complain if you’ve significantly increased their premium when they renewed their policy.

  Insurers normally consider various factors when deciding the premium, including:

  • previous claims
  • the animal’s age and breed
  • the general volume of claims made by all customers

  It's not for us to tell you what price to charge for covering a particular risk. But we can look at whether we think you’ve acted fairly and reasonably in the way you’ve set the premium. This might involve asking for underwriting criteria and a breakdown of factors which caused the price to increase.
  
  If we think you increased the premium to unfairly profit from a particular customer or  group – or to put them off renewing – we’re likely to uphold the complaint.

  We’re also aware of concerns about the rising costs of policies that include a continuation benefit or ‘lifetime’ element.

  Any type of continuous cover can also have benefits that would be lost if the policyholder changed provider. So, to enable customers to make informed decisions, it’s important to give the customer enough information about any future price rises before they out take the policy. 

• Complaints about equine policies

  Equine policies often provide cover if a horse has to be put down because it’s severely diseased or injured. Claims are usually only covered if the decision is in line with the BEVA guide to best practice when considering euthanasia on humane grounds.

  According to BEVA guidelines, a claim will only be paid out if:

  “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.”

  Customers sometimes complain that although a horse was put down for humane reasons, the insurer won’t cover the claim because the euthanasia didn’t comply with the BEVA guidelines.

  In these cases we look at the policy wording and check that the procedure was carried out in line with the guidelines. For example, this may be where:

  • the condition was so severe, the horse had to be put down immediately
  • the insurer was contacted, or another vet was asked to give a second opinion

  Some equine policies say specifically that the BEVA guidelines must be complied with for a claim to be paid. But other policies may use different wording. For example, it may say that a claim is only valid if there is no other option of a cure or treatment and that euthanasia is ‘imperative’, but doesn’t specifically mention BEVA.

  In both these cases, if evidence shows that no alternative treatment was available and it was necessary to euthanise the horse, we’re likely to uphold a complaint.