£6,000 PET insurance claim denied! do I have a leg to stand on to appeal!!

[PRINCEY100]

Hi everyone,
i really need some advice and would like to hear if anyone has been in the same position before.

My horse had a tooth removed in May last year, the tooth was fractured and the vets put it down to trauma as you know horses can get up to no good in the field with other horses. There was nothing wrong with this tooth prior to the fracture and he has had yearly dental examinations which prove so.
I put in a claim with my pet insurance (policy started jan 2021) and they came back with a response to my vet practice asking if the tooth was diseased or due to trauma (as the insurer does not cover dental/gum disease but they cover injury etc.). The vet responded that this was a traumatic injury as the tooth was not diseased and yearly dental exams show the tooth was healthy. (horses can cope with chips in their teeth)
Now this is where it becomes tricky…my horse chipped part of this same tooth in 2018 but as I mentioned it was only a chip and just so happens that 4 years later
he has fractured the same tooth from trauma to the face!!
They are now saying that this was pre-existing as my policy started in 2021 and I didn’t mention the chipped tooth to them before taking the policy out, and if they had known about it they would have just excluded this from my policy.
(they also denied my claim 10 minutes after asking for a response from the vet, which is really weird. My vet responded a day later but they had already rejected at this point.)
I have been to the financial ombudsman to file a complaint on my behalf, but the insurer has 8 weeks to respond.

Just wanting to know your thoughts on this, 6k is a lot to pay and I don’t have the money to pay the vets!! Pet insurance for a reason, what’s the point!!

This was their response:
It is apparent from the clinical history submitted that your horse was previously treated for fractured tooth 2018. Had this material fact been disclosed at the inception of your insurance contract 2021, this would have allowed us to make any appropriate changes to the terms offered before the contract came into effect.
For the purpose of clarity please may we courteously refer you to the applicable sections of your policy wording, namely General Exclusion 1 and Your Promise, which clearly states: -
1. Any medical condition that existed or is connected to a condition that existed before the insurance policy began.
And
You promise that your horse is sound and in perfect health at the start (and renewal for non-lifetime cover) of the policy term, and that your horse does not have any illness or injury save those notified to us. Any horse that does not meet these health standards will not be covered for any illness or injury present at commencement of the policy term.
As this condition has been confirmed to have been present prior to the inception of your policy contract with us, we regret to inform you that we are unable to accept liability for your claim.

I think you have to disclose anything they have sought vet treatment or advice for.

My cat is excluded from any hormonal or mammary conditions because the rescue Centre asked vet advice about swollen teats. There was nothing wrong as it was normal hormonal changes due to a pregnancy. Despite there being nothing wrong and it being a completely normal finding they still put the exclusion in because a vet had seen her for this “related” condition.

Thanks for your comment, i just think insurance companies are awful. when i took the policy out i selected no to the questions asking about injury and agreed that my horse was in good health which he is, it doesn't ask you has your vet ever treated for anything. Plus it was 4 years ago its just so frustrating.
i have called the vets out a few times for lameness prior to my policy starting but this was always mild lameness and due to either stones in the hoof or a mild sprain. now I'm thinking would they ever cover him for anything relating to his leg god forbid!!?

No advice but 6k for one tooth to be removed?

Who is your insurance with? I’m pretty sure I can guess. I would never think to mention a chipped tooth, it’s absolutely not relevant to anyone with common sense but they are arseholes looking for any excuse not to pay.

My friend once had a claim refused because her horse was injured in the field and she’d mentioned on the phone when making the claim that she’d taken her horse xc the day before and they
refused it because the horse wasn’t covered for xc!!

Generally, if you go for a company that has a cheaper premium, they don’t actually give you good cover and will do anything to get out of paying claims. (Apologies if that is not the case for you).

Thanks for sharing! i am with insurance emporium paying £40 a month, my horse is only 10 years old and doesn't have a huge medial history. Have only called the vets for mild lameness and the tooth. I mean what do you actually do with a £6k vet bill!! i am thinking to leave them after this but again i'm lost with who to go with, i always felt at ease knowing my horse was insured and it just feels like ive paid for nothing.

i cant believe what happened to your friend. how can they possibly have said it was because of XC when the injury was in the field?! did she appeal their decision at all? What injury did your friends horse sustain?

I imagine chipped in such a way it couldn't be pulled out without surgery

I get that surgery was probably needed but still.

I assume these costs are in part due to insurance often paying out. Imagine if insurance wasn’t so common, I doubt vets would be able to charge that kind of price.

Unless of course this was an unusual case which needed lots of extra treatment.

You are correct, the tooth was healthy so couldn't be removed orally, had to return a week later for surgery. £6k from initial emergency call out, diagnostic imaging, initial attempt at removal, surgery with a specialist and imaging during surgery also, following by twice weekly visits to clean the socket.

The tooth was healthy so couldn't be removed orally, had to return a week later for surgery. £6k from initial emergency call out, diagnostic imaging, initial attempt at removal, surgery with a specialist and imaging during surgery also, following by twice weekly visits to clean the socket.

How good is your relationship with the vet? My insurance quibbled an abscess (due to penetrating injury) as foot wasn't insured for lameness. But the horse was covered for injury anywhere.

Vet told insurance company in no uncertain terms (after I told them what they were trying to do) that it was not a pre existing condition and they paid up. It was all a bit traumatic for me as he had been pts as a result of how bad it was.

So get your vet on board and see if they will write that this is unrelated to the chip.

Thanks for your response and sorry to hear about your pet, i have a good relationship with the vets but funny thing is my vets actually wrote a response saying it was due to trauma, but before they got the chance to write a letter back the claim was already rejected. (I guess as they found another way to reject it by saying it was pre existing and not even quibbling over weather it was trauma or dental disease.)

i guess my situation is slightly different as the insurance are saying that specific tooth already had a fracture, so it was pre-existing, they call it a fracture but in 2018 was literally a small part of the tooth that had chipped off.

its just a horrible coincidence that due to a trauma his tooth had been affected.

Do you think its wise to appeal this?

I hate to say it, but insurance jump on anything not mentioned. You are right that this is trauma and not an old injury, but the fact you didn't disclose the pre-existing chip sounds like it legitimately invalidates your insurance.

Sometimes companies will refuse a refund or reject a claim as their first response.

It seems the crux of your claim is whether a chipped tooth could cause a fracture 4years later, and if this is due to disease or injury. It sounds like your vet agrees with you. I do too.

Keep going with the ombudsman. I have a Which subscription and pay for their legal advice. I have used it a couple of times. Once for an after purchase discount which they said had lapsed and the second time the company wouldn’t replace a faulty item.

They rely on people giving up too easily. The insurance company wont care that this is a huge worry for you.

Even if you move insurers anything that’s been treated for previously wouldn’t be covered generally
I would ask vets for a complete copy of medical history so you know what would and wouldn’t be included in insurance

this often happens with dogs
gone for a check at a puppy vet mentions something like might need boas or they have antibiotics for a bad cold
then you insure

then when you need to claim for boas surgery it’s not accepted as they class they fact that’s the vet put it on the notes as a pre existing condition

i have the medical history but theres nothing major on there. i thought they could only deny a claim if they found it to be related. not just because its the same area.
and i was thinking to move insurance because a lot of companies state that if no treatment has been received for 24 months then they cover anything. which is why i was surprised they picked on something from 2018!

hiya, thanks for your advice. I did think that maybe if i appeal i might get a different outcome. and yes there's no way that the two are related 2018 and 2022 because the dental charts for years show he had healthy teeth, never ever been called out for an infection either.

But what's really annoying is that the clause in my insurance policy states "something that first showed clinical signs". which the tooth did show clinical signs of fracture in 2018. but technically is a small chip. then in may 22 he was brought in from the field one day then started salivating then swelling was visible, so called the vet out. He had a large 10cmx5cm tongue laceration also when the vet arrived and looked. it needed removal due to the fracture affecting the pulp horn.

I will look into that which subscription, how much do you pay?

The advisor will be told to reject as much as possible. a chipped tooth is in no way a related injury regarding the complete mess you described the tooth to be in this time. No treatment was sought and there was no other damage to the tooth and it was regularly assessed. This injury was purely due to trauma as advised by the vet.

Keep going with your claim against them they are being unreasonable

I worked in health insurance and used to assess claims and send those letters out (not email back then lol) and its the first stop if there is ANYTHING at all vaguely possibly, potentially related.

Yes appeal they rejected my claim twice and then I got the vet to speak to them on the phone. That sorted it out. Good luck.

They have jumped the gun in refusing which is infuriating but also their reasoning is quite straightforward to refute so keep going.

It is apparent from the clinical history submitted that your horse was previously treated for fractured tooth 2018. Had this material fact been disclosed at the inception of your insurance contract 2021, this would have allowed us to make any appropriate changes to the terms offered before the contract came into effect.

Their refusal relies on saying that the tooth was already fractured but not disclosed, not that the the tooth was chipped but you hadn’t told them.

The vet will confirm he was not treated for a fractured tooth in 2018 (and none was subsequently diagnosed) therefore you did not not fail to disclose a material fact.

I would write to them again clearly stating this and you might get a resolution without going to the ombudsman.

The ‘showing clinical signs’ isn’t relevant because a chip does not necessarily mean a fracture. If there were clinical signs of a fracture your vet would have said so and noted it down.

If they wanted to argue that the chip led to an fracture that went unseen/undiagnosed until it exploded then they should have worded it that way but that would be difficult for them to prove, especially as you have yearly inspections, so from your point of view what they have claimed is easier to refute.

Keep it simple and use their own wording back at them and keep going with it all the way even if they don’t see sense immediately. They are just trying it on.

Completely unhelpful but I'm just dreaming about an insurance premium of £40 a month. My two cats currently cost £118 a month and that's a reduction on last year!

oh wow really, god insurance is awful!
i have contacted the ombudsman but do you think i should appeal myself and send a response back to the insurer?

They asked my vet to comment on the injuries. then rejected the claim the same day, my vet then responded the following day. so I don't even think they considered what my vet had written to them.

i guess in a way it looks bad because the medical history in 2018 states fracture, but the vet had explained on the letter that it in 2018 it was a minor piece of tooth which chipped.

can i ask why they rejected your claim and what was the inuruy/illness?

I worked in insurance for a long time.

Insurers do not want to pay out. They just don’t, it’s not in their interests. If their policy wording states that you must declare all previous injuries/illness and you haven’t then it is likely that your policy is void.

It is infuriating but it doesn’t matter whether the chip was the cause or not - it will say somewhere that failure to provide correct information will result in your policy being invalid or similar, and that is what they will use as the reason for declining your claim.

They are fuckers and the best advice I can give to anyone is whether you think it matters or not, whether it happened 10 years ago or not, declare it. Do not give them any reason to decline your claim, because that’s what they’re looking for.

They what?! Who the hell are you insured with and what’s the cover like? I have platinum cover for all three of my cats and I pay around £35 IN ALL!

@WetBandits we've had £22k of vets bills. Most of that is one cat. The other I think is about £30 of the premium. They are both Persians.