£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.

This. A chip is not a fracture.

Does your vet report say fracture on 2018?

in the clinical notes they would need to use the correct terminology, so a piece or enamel had broken off. which is technically a fracture.

it states:

2018:
fractured lingual portion of 309 to gum
line, removed as loose fragment. No other fractured
portions

Then in 2022:
Sedate and extract tooth 309 with rostral crown fracture affecting 1 pulp horn.

I agree insurer's are fuckers but when similar happened to me I rang and checked with them (nfu) before I gave the go ahead to the dentist. I use an extremely high end equine dentist. Needed a filling and a mend of a broken tooth. No extraction. It was approximately 1.5k for both teeth. I think 6k is extortionate.

That definitely looks as though the two could be connected sadly.

Lingual and rostral are different sides of the tooth so it can't be the same fracture. Just keep pushing. Get reports from your edt from and filing work they did. A fractured tooth with annual filing would likely have broken in the last 4 years if still present

Sadly insurance companies - any kind - will take every advantage to get out of paying up they can.

The onus is completely on you to have disclosed any relevant information, and they rely on people forgetting to.

I guess yours is a little different as they already made one attempt to remove, then had to surgically remove the tooth. He needed a lot of x rays and aftercare also as he literally had a hole in his face and chin.

the 2 incidents were not connected, the tooth was healthy and the horse displayed signs of distress and swelling from coming back from the field. Hence why the vet said it was a traumatic injury.

Poor boy. My other horse had a standing leg operation at Donnington with three days livery and 3 months aftercare and even that wasn't 6k!!

I feel for you insurer's are fuckers. My insurers basically told me to claim more when I complained about the cost - 289 a month for two horses 🤕

I'm cancelling at the end of this cycle but in the meantime am planning to claim for everything I can

JEEEEZ i really do feel ripped off!!

I've just found the bill and it was less than 4ķ in 2020

oh my goodness, why so much? is it their ages?
better off saving that money each month...as if the cost to keep and maintain them isnt enough without adding 300£ on top.

My sister had insurance on her cat declined. Eventually we got them to pay.

You need to be able to prove that chips on teeth are common and not harmful and therefore do not need to be reported. Then you need to show that the chip does not mean that the tooth was previously fractured and is therefore separate from the new injury. And for all of that, you need the vet to to write a report.
See what is on your medical records about the tooth prior to the injury. Then speak to the vet to see if he agrees the two incidents are unrelated. Then write an email to the vet outlining what you need them to write in the report. Then he can send it off in support of your claim. Remember, it's in your vet's interest that the insurance claim is approved.

I would continue with the internal appeal procedure with your vet's support.

I'd also call and ask about the exact arrangements for pre-existing conditions. With some insurers and some conditions, there is a window after disclosure in which they're not covered, but once sufficient time has passed that condition can be included again. I suspect this is mainly used for the type of injury that may develop into something, but may instead settle down and not cause any further problems - my Cavalier King Charles spaniel had an eye injury from too much rabbit digging and he wasn't covered for eye injuries for (I think) a year or two after that, but then it was added back in. If this is the case you might be able to argue that even if you had disclosed it, it wouldn't have made any difference by the time of the second injury.

I think you’ll struggle on this if I’m honest. It’s not proving that the two are unrelated it’s that you didn’t declare it when you joined. If you had they’d have probably excluded cover for that tooth.

There was a case on Rip of Britain last week where a woman's £65k travel insurance claim for a brain tumour operation was refused as she hadn't said that she saw her GP for headaches a few years before.

She used a comparison site and so they did not ask her specific questions about visits to the GP.

The experts said that the way that insurance is taken out needs to change because at the moment the insurance companies can just reject claims if you don't tell them absolutely everything even if they hadn't asked you about it.

They are 14 and 16 so yes older, but I've been with my insurers for 10 years with one and 7 years with the other and claimed twice so hardly a risk!!

Cheap insurance is rarely good insurance

This is awful, but typical I'm afraid. We had similar happen and nothing paid out. But it's worth speaking to you vet. Ours we're sympathetic and significantly reduced the fees when they realised our insurance wasn't covering it. I think they charge top whack when they can but in reality they can reduce fees at their discretion. Good luck

If I was an insurer I'd definitely consider those two things connected if they're related to the same tooth.

In future, always get a pre-authorisation from your insurer.

Surely you’ve nothing to lose by sending a letter back pointing out that the vet clearly states that the two incidents are not related and that they seem to have not taken the medical professional’s opinion into account.

I hate insurance, I don’t have it for any of mine. We had a savings account and a credit card. Despite a couple of hefty bills we’re still winning (just).

I also agree that vets sometimes do more procedures than are necessary if they’re insured, particularly nowadays that most vets are big firms, and bills go higher because of that.

I wouldn't class it as cheap, he is a young horse still and doesn't compete at all. average costs would range from 40-50 for his type of 'use' and age and also how much he is insured for vet fees wise.