£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 know they will find anything to say, sorry we wont pay.
That's absolutely awful, did you put a claim in the end?

The vet confirmed it wasn’t related.

I take that to mean has your horse been treated ever for any injury in the second part of what you quoted. And because you didn't declare the tooth they will be able to exclude. I'm sorry

@LittleLillie but it was still a pre-existing condition that wasn't declared. The insurer can claim that invalidates the policy.

If the word fracture is mentioned on the notes in 2018 that does complicate matters but the vet did not see or record any evidence of a crack and noted no other damaged portions so it’s worth pursuing anyway. Clarifying it in the notes as a ‘chip’ not a crack and giving more detail and size etc would have been helpful but what’s done is done.

Do you still have the fragment of tooth? Send a photo as evidence. They still have to argue against the vet’s opinion that it is unrelated.

But the wording of the questions about existing conditions or treatments is going to be key. Any wiggle room and they will find it. They would need to show that had they known about the chip/fracture then their normal policy would have been to exclude that tooth for example.

How big was the original chip?

If it was small, surely it would have grown through and been rasped away after 4 years? I think it’s a bit cheeky to count it as a pre-existing condition to be honest.

With my claim, they argued it was arthritis before speaking with my vet, but once the vet had clarified it was an injury (the whopping great cut on her shoulder made it pretty obvious) they paid it.

A chip is still an injury. Unfortunately, you didn't declare it. Similarly, the lameness will come under examined/treated/diagnosed with an injury.

In pet insurance, they will exclude the whole area. So previous grass seed in rear will often lead to an exclusion for any ear condition.

I get why you feel determined to argue it but the point is that the asked you has your horse ever been treated for any injury and you said no. You invalidated the contract by lying through omission. THAT is the issue you are fighting against, not whether or not a chipped tooth contributed to the later fracture.

This is the issue.

Very annoying but any insurance with this clause will get you if not careful

This is what I’ve said all along, not that it’s pre-existing because it isn’t, but that the OP didn’t declare the previous damage to the tooth. They will decline on this basis.

This was a large amount to claim. So the insurance company has looked at this closely and found there was a previous injury to the tooth. It's annoying for you but I can see why they denied your claim.

Hi all,

just thought I would give an update on the claim. i had a response this morning and they have agreed to overturn the decision and cover the amount in full! i am so over the moon with the outcome and so relieved, its a massive weight off my shoulders...it just goes to show you that insurance will look for anything to refuse a claim hoping you will just accept. The handler agreed with both me and the vets that it was clearly traumatic as during the 4 years the tooth proved not to be problematic, and to have had sudden onset symptoms supports the vet opinion that it was a trauma. therefore this was not considered a pre-existing condition.

i had a response this morning and they have agreed to overturn the decision and cover the amount in full! i am so over the moon with the outcome and so relieved, its a massive weight off my shoulders...it just goes to show you that insurance will look for anything to refuse a claim hoping you will just accept. The handler agreed with both me and the vets that it was clearly traumatic as during the 4 years the tooth proved not to be problematic, and to have had sudden onset symptoms supports the vet opinion that it was a trauma. therefore this was not considered a pre-existing condition.

Fantastic news!!!

That's fantastic! Thanks for the update.

Thanks for the update. Great news.

Pleased you got it all sorted OP. A big relief I’m sure.

Speaking of relief, could I make the polite request that in future, you take a little more care in your choice of words when posting about this kind of stuff? The reason I’m asking is I read “My horse had a tooth removed in May last year, the tooth was fractured and the vets put it down”, Which I found a shocking outcome to just a fractured tooth. And then I kept reading...

(Not serious, just for those about to get on their high horse. Pun fully intended).

That’s great news. Glad they agreed to cover it.

My bill was £1200 in the end, and I panicked when they first refused, I think I would have died at £6k!

I don’t think I’d have thought to declare small chip off a tooth as a previous injury either tbh. My OAP has a missing tooth that we declared (and they obviously excluded) - she has to see the dentist every 4 months to have the one below rasped (honestly, she’s a walking money pit!), but a small chip off an otherwise healthy tooth? I wouldn’t think to declare a previously chipped hoof either 🤷‍♀️

She’s only insured for injury and liability now anyway as she’s knocking on a bit.

LMAO! I’m not sure how you read that so wrong 😂😂. The sentence did not stop at “the vet put it down”. Which obviously wasn’t the outcome.
anywho…yes a huge relief

a vet bill is never pleasing for anyone 😭 no matter what the cost…although my policy states I pay 17% of my fees so I actually have a £1,100 bill to pay also, but still better than 6K!! And yes I did nearly die when I saw the outcome!! I think now that I know this wasn’t classed as a pre existing condition I won’t worry as much for the previous lameness call out. The only time he was lame was because he was transitioning to barefoot and his feet didn’t cope. So had an abcess on either hoof. Never an injury etc And bruising to the hoof is not a pre existing thing.
at least you are insured for injuries that’s always the main worry for me

Oh that's good news!

The onus is on your insurer to prove that your claim is not covered. You need to ask your vet for a report. Ie in your vets opinion, was the tooth weakened by this chip or can he put the crack solely down to one single incident, I imagine your vet has prior knowledge of the chip and you were acting under medical advice the it needed no further attention? The Insurer are not vets and are not in a position to question someone who is a qualified expert. If they are not happy with your vets explanation then they must provide their own expert to look over your vets paperwork and previous health checks. It sounds to me that your claim handler doesn't really have an indepth knowledge of horses. Have you checked your policy wording and exclusions?

Horses' teeth grow all the time and a chip four years ago could very likely have grown out by now.
If your vet says it's due to trauma, the insurance should cover it.
The only way the insurance company can avoid paying is to get a second opinion from another vet to say that the chip caused it. That's going to be impossible to prove.
A chipped tooth isn't a preexisting problem, because that's normal wear and tear for horses' teeth.

Glad it's resolved now

So pleased for you OP! Well done 👍 Hope you’re horsey has no more mishaps!