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Since I don't belong to any horse forums, I thought I'd quickly try the hivemind here.
I won't provide too many details as don't want to prejudice anything.
We took out an insurance policy on a horse that we had fully vetted before purchase.
The insurance company accepted the vetting and issued a policy with no specific exemptions from the cover.
Horse was diagnosed several months after purchase with a condition that requires expensive treatment.
Insurance company are declining to pay, claiming that the condition must have been pre-existing at time of purchase/commencement of cover, even though not picked up during the very thorough vetting process.
Anyone have any experience of challenging anything like this, or seeking redress from the vet? Any recommendations of specialist solicitors?
I do specialise in insurance stuff, but I think the main question is would it be worth your while in terms of cost/benefit.
If you're talking hundreds, probably not, but if you're talking thousands then possibly.
If you don't want to pay for a solicitor, have you used the Financial Ombudsman Service? It's free to complainants (they charge the business a fee) and the Ombudsman has pretty broad powers.
as above - I'd exhaust any statutory complaints process before throwing lawyers at them. However if you cna find a specialist who'll give/sell an hours advice in advance of escalation it might mean you don;t go some blind alleys.
It's a horse, you're looking at 000's in vets bills in the first week!
The issue that I think you'll hit is that there's generally a waiting period for chronic conditions so you'll need to check your policy very carefully.
Firstly, does the policy you've purchased exclude pre-existing conditions? A quick glance at your policy wording will tell you.
Secondly, Is the condition you refer to one that was pre-existing before the purchase of the animal?
It's the latest in a series of increasingly large ponies->horses, so familiar with bills, but not quite at this scale.
Yes, the policy excludes pre-existing conditions (as implied but not explicitly stated in my original post).
We don't know definitively whether the condition was pre-existing.
Unfortunately there is *something* in the vetting notes that the insurance company claim shows it was pre-existing (effectively a pre-cursor to the condition that we'd like to claim for). However, it was merely a fairly innocuous observation by the vet.
Where I've had a pre-contract "survey" before (e.g. house survey, car report) the expert is usually at pains to explain the worst case scenario (wet rot, subsidence etc) if they make any observations, whereas here there was no warning of what it might be (whether it was or not).
I increasingly feel the vet has let us down - by noting something, but without telling us the worst case of what might have caused it (in which case we might not have completed the purchase) - he's given the insurance company something to build their case on.
You have a couple of choices - one is to pursue the insurance company. You have a reasonable chance of success at FOS and you could argue that if they are relying on something in the report they accepted to now deny a claim they should have brought this to your attention if it is so significant.
The second option is to pursue the vet if you feel they have not fulfilled their duties to you.
Personally I’d write a letter to the insurer on the basis above and tell them if they won’t change their decision you’ll take it to FOS.
I deal with insurance complaints and FOS all the time and they are pretty strict on insurers drawing customers attentions to anything relevant to the cover.
The insurance company accepted the vetting and issued a policy with no specific exemptions from the cover.
IANAL, IANAV, nor am i a horse expert.
But you had the horse examined before buying, which picked up a potential precursor condition but which wasn't properly explained to you by the vet. Sounds like the vet has let you down here, but maybe also you didn't ask the right questions.
When you say the InsCo 'accepted the vetting' did they see the full report (and have the chance to ask the same questions that you didn't) or was it just a case of 'we've had a vet look at the horse and they said it's OK'
As above, did the insurance company see the report?
If they did then they don't have a leg to stand on. You are not a vet, you paid for a vet to do an examination and presumably sent them the report for them to check. If they had seen it and come back with "we noticed this which could be a precursor to X so we won't cover X.then that would been sensible.
Another thing to be careful of is was there a period to allow for something underlying to surface? Normally you would expect a couple of weeks but no idea for a horse.
If they didn't see the report then I would looking towards the vet but not all guns blazing. It might be a case that the thing that was noticed was a precursor and not the actual condition and they may be able to find a justification to help your cause. something along the lines of having high cholesterol doesnt mean you are going to have a heart attack.
As dannybgoode says, complaints procedure and fos.
Have you looked here?
https://www.financial-ombudsman.org.uk/publications/technical_notes/pet-insurance.htm
<h3>where the pet had a pre-existing condition</h3>
Most pet insurance policies do not provide cover for pre-existing conditions. If an insurer declines a claim on the grounds that the pet already had the condition before the policy was taken out, we will look at how much the consumer actually knew when taking out the policy.
We might say that it was reasonable for an insurer to reject a claim if we think that the consumer knew about the condition when taking out the policy. Or where the policy excludes pre-existing symptomsas well as conditions, we will decide if we think the consumer knew about any symptoms that raised a clear possibility of a future claim.
There is more information about our general approach to complaints involving pre-existing conditions in our online technical resource.
P.S if you want to share which insurer it's with I might be able to shed some light on their MO. Pm me if you like.
Just resurrecting this to say thank you to everyone who posted advice. After a protracted exchange with the insurer we took them to the FOS who ruled in our favour. No lawyers were required and the insurer paid in full.
The irony is that this same horse later became lame so we put her out to pasture and got another one.
Moral of the story (which everyone knows anyway) is keep your kids away from horses.
Bikes are better. I have a colleague who spent thousands on her young male horse - was always injuring himself - one was quite bad - split a hoof badly - lots of blood etc, long time to heal.