£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.

How? It’s like you having a chipped tooth, someone smacks you in the face with a baseball bat and knocks out the same tooth. Was the cause the chip, or the trauma?

Its irrelevant anyway, the insures have declined the claim because something they deem as relevant wasn’t declared. They can decline the claim and cancel the whole policy based on that tiny detail, and they will.

Not surprised in a way sadly.
My cat is with petplan who have been fantastic
But a common or garden moggy is £52 a month

they have denied the case on the below basis.

1. Any medical condition that existed or is connected to a condition that existed before the insurance policy began.

But its not even connected ffs!! its really frustrating. im trying to put together an appeal letter.

It’s the first bit then - any medical condition that existed before the policy began. They really are fuckers.

Have you officially appealed the decision or entered the insurers complaints process? Usually once it's a complaint someone slightly more senior looks at it and you may get a different outcome. Maybe not. Have you got your policy terms and conditions? What does it say about declaring previous medical conditions?

Gosh, that's awful. No advice at all but this is exactly why I don't pay for pet insurance, they always find a way out of paying up. I just put money into an account each week. Understandably slightly different with a horse though. I hope you get it sorted, you sound like a responsible horse owner and you don't deserve to be screwed over.

This is why pet insurance is bullshit

This is why I ceased to insure my horses, and instead put money aside in a savings account. It also gives me back control, and peace of mind.

As a bonus, vets are a lot less likely to do unnecessary investigations/treatments if you are uninsured.

@LittleLillie as far as the insurance company know, the original injury could have weakened the tooth, or caused the horse discomfort so he'd hurt himself trying to get rid of the pain

You have nothing to lose by going for it but I think you're unlikely to get anywhere. If you'd have declared the previous tooth injury they'd have probably excluded all dental work period, because that is what pet insurers do. Your best bet is to get your vet to write very clearly that the one did not make the other more likely to happen, but I think they are going to remain within their rights to refuse to pay, as you did not declare a pre-existing condition as you were contractually bound to do. It really sucks, I'm sorry but that's how it is,

How is pretty obvious. To the insurance call handler (who has no veterinary knowledge), the chipped tooth was the only tooth to be affected by this “trauma” so it looks like the chip weakened the entire tooth and made it more susceptible to injury.

Regardless it sounds like the vets rejected the claim before OPs very even provided further information so it certainly needs investigating.

I haven't yet appealed formally, i am currently trying to collate a letter to send over with dental examination charts from the last 2 years.
they can argue i didn't mention it but its not as though it was an injury the first time, he actually ate something in the hay. horses chip teeth all the time, they're constantly growing too which is why they need checking and filing yearlyy and in 2018 it was such a tiny part of tooth that chipped away i remember keeping it.

Can you appeal through your insurance company with your vet’s support?

I had a claim refused for my OAP. She has arthritis, which is declared and excluded, but she got a nasty field injury on her shoulder that needed X-rays (they thought she might have a fracture originally) and stitches, etc.

It was originally refused on the grounds that it was related to her arthritis but our vet sent them a very thorough report refuting that it was anything to do with her arthritis (no evidence of arthritis in that area on the X-ray) and they paid out in the end.

I would fight this tooth and nail and not stop until they paid out!!!

It's outrageous that they've said no. I am sure the mere mention of the Ombudsman will have them changing their minds but definitely appeal anyway.

the tooth was not weak, it was a perfectly healthy tooth. after 2018 it was assessed yearly, never had any infection or anything like that.
they call it a fracture as the tooth is technically bone, the fragment that chipped off had nothing to do with the traumatic crown fracture 4 years later.

OH REALLY! i guess this situation is sort of similar but for me the diagnoses between the 2 incidents is so similar which is why they have rejected my claim without haste.

yes your right the insurer rejected the claim and sent me an outcome before the vet even responded back to their query. the insurer was asking the vet if it was related to teeth or gum disease from 2018 and was due to it not being removed in 2018. they then denied the claim before getting a response. Perhaps because they saw the policy start date was after 2018.🙄

What a nightmare for you. I can see how they can try to avoid paying as it wasn’t recorded.

Not that they have to be related but just due to the clause

Anyway maybe you can fight it not sure though

The real issue is those doing the initial assessments are generally not vets or have any animal medical training - so if anything is more technical they just don't know and things a rejected automatically. SO if you go in with a more technical assessment they would then refer to a vet or trained person who might have more of a clue. Get Vet to give you a "report" indicating chip not related to new fracture which was trauma related not related to prev fracture on different side of the tooth - the sentence of no further fracture located is critical in this instance and will help you out. I would fight it direct with insurer first myself as generally for a complaint to ombudsman you have to persue all other internal routes including formal complaint first - faster resolution for you to directly challenge the insurer and speaking to people higher up than putting in complaints etc.

In terms of paying your vet agree a monthly pyt - on the basis that if then settled its returned to you. THe Vet may be helpful if you sweet talk the as they and their staff deal with this all the time so they may also have contacts etc

A family member is in a similar situation (I actually read this to see if it was them!) with a claim for their DDog.

They appealed and have already had part of the claim paid. When speaking to my own vet, she said that they manage to overturn more appeals than not and it is almost a default for the insurance company to refuse to pay initially.

I will never buy equine insurance again - after a few years the only thing they’ll cover is the bottom 12” tail.

I was in such a state with a sudden “catastrophe” with my last - PTS fast was the only kind/sensible option, it didn’t even cross my mind to get “pre-authorisation”.

The entire thing was so traumatic the last thing on my mind was recouping costs.

The fuckers actually send me a FLOWER SEED to plant in memory. 🤬

thanks for your comment your advice is really helpful. i am writing an appeal letter to send off. i've just gone on the policy document and there were 2 questions i answered no to, i mean how are they saying i didnt declare it, where is the option to declare it. minor piece of tooth coming off doesnt even come under this, could understand if it said dental.

In the last 12 months, has your horse been seen by a vet (excluding vaccinations)? If so, what for and when?
No
Ha.s your Horse ever been examined in respect of, treated for, or diagnosed with: an allergy
.any injury
.arthritis or osteoarthritis
.colic
.degenerative joint disease
.desmitis
.epilepsy
.gastric torsion, dilation or bloat
.growths, cysts, tumours, cancer or equine sarcoids
.any heart condition or heart murmur
.hip dysplasia
.laminitis
.sprained or fire tendons, or been denerved
.any skin condition
.any urinary

aww glad they are sorting it for you though, what was the injury/illness for the dog? and why did they reject?

If you read it the first bit says has your horse seen a vet / treated in the last 12 months

the 2nd question doesn’t mention the last 12 months so basically asking if at anytime since you have owned the horse has it had xxxxx.
Has your Horse ever been examined in respect of, treated for, or diagnosed with: an allergy
.any injury - this is what they are referring to as they obviously see the 2018 tooth incident as an injury even if it’s clearly not

by not putting in the last twelve months on question 2 … and writing has your horse “ever been treated for “
that’s how they can get away with not paying
because your horse had an “injury” in 2018 in their eyes so you haven’t disclosed that previous injury so they won’t pay out for any injury related to that injury

yes i get that, thats exactly what i thought too/ However if only anyone could have seen the bloody tooth that was chipped. it was so tiny and minor and gave him a little tooth ache, never had any problems after that. Apart from trauma to the face. i feel like the way the notes are written make it seem like the same thing happened twice