pet insurance issue

sarahlynnesmith

Hello all

We recently lost our dog aged just 5, he fell ill suddenly and was diagnosed with a brain tumour. The diagnosis was made after an emergency referral to a specialist hospital. At the time of diagnosis we were 16 days in to a brand new insurance policy (so outside the 14 day cooling off period specified in the t&c) The specialists did a vast amount of tests and tried surgery etc but the tumour couldnt be fully removed and we had no choice but to euthanise. I wont specify figures but between everything the bill is substantial, but we have always elected to pay for as much cover as we could afford. The insurance company have declined our claim and are saying that the tumour was 'pre-existing' despite the fact we had no idea he was ill. 

We had taken our boy to the vet around 3 weeks prior as he took a tumble down some garden steps while playing at my Mum's and was not himself after it. The vet gave him a good examination and diagnosed muscle pain they told us to let him rest for at least a week then gave us anti-inflammatories which we paid for ourselves. Around 2.5 weeks later we came home to find him howling in agony on the floor and urainating uncontrollably which is why we rushed him back to our vets. I believe they are trying to link the muscle pain with the tumour to avoid paying.

We have asked for a review of the claim and plan to appeal if the review fails. Does anyone here know if the insurance company can refuse to pay even though there is no mention or evidence of a Tumour on any of his veterinary records until we went to the specialist hospital? In fact our local vets had no idea what was wrong when we rushed him in which is why we were referred to the Hospital in the first place.

elsien

I think the brain tumour diagnosis is less relevant than the point at which it was clear that something was wrong and he needed the referral to the hospital? Where does the urgent vet visit and the hospital referral fit into the timescale of your policy?

When you took out the new insurance did you declare the vet visit for the fall? 

DullGreyGuy

Presumably you had switch insurers?

What does your vet say? Did the tumour just come into existence in the last 16 days or is it likely it was there before but just not causing any problems until it grew more? Is the fall likely to have been caused by the tumor.

You also need to look at the exact definition of pre-existing condition in your policybook and any associated terms... some will only exclude things that had prior symptoms or diagnosis whereas others dont specify symptoms and so will also exclude asymptomatic conditions that subsequently develop symptoms.

sarahlynnesmith

elsien/dullgreyguy - yes we switched insurers as the premium had doubled from the previous year despite the fact that we had never made a claim with any company. The urgent referral was given after the 14 days. We never mentioned the fall as we didn't think of the fall as a 'condition', he just fell and hurt himself while chasing a ball. He was quite a lumbering fella when running who often tripped over himself. The visit about the fall was the first one he'd had for any reason outside going for booster jabs every year.

As you can imagine we asked the vet at the hospital if we could've pre-empted this as we felt terribly guilty and upset that we couldn't save him. The vet at the hospital said that the tumour was only 1cm in size when they diagnosed it but in a very diffcult place in terms of removing it and that we would never have seen it coming or known it was there without their tests. The time from when we found him in agony on the floor to euthanasia was just 5 days. Physically he was strong as an ox but in the days he was in hospital his temperament changed which is what the vets main concern was. Otherwise we would've been able to nurse him at home for his final days/weeks/months.

Our local vet had no idea what was wrong and no mention of a brain tumour was made until we were referred urgently to the specialist hospital. He was a very healthy dog who we adored and took excellent care of. Our vet asked us every time we went there what we fed him as he was lean and muscular with a shiny coat and told us how refreshing it was not to see an overweight labrador.

DullGreyGuy

Who is the policy with? What is their definition of pre-existing condition? 

This will be one of the key elements as, as mentioned above, not all pre-existing clauses are limited to conditions that have symptoms. Assuming your's effectively includes asymptomatic conditions then it'll be down to expert opinion on if its likely that the tumour existed at the point of purchase or if its more likely it developed only in the last 16 days.

With all medical insurance, for humans or animals, there is always a risk with switching insurers because of both these types of exclusion clauses plus normally a 14 day exclusion period at the start of the policy.

sarahlynnesmith

dullgreyguy - purely pets 

we knew about the 14 day exclusion as that has always been standard in all policies since we've used pet insurance. When we took him the 14 days had passed, granted only just but they had still passed. 

sarahlynnesmith

dull grey guy - if the conditions don't have symptoms how is anyone supposed to know the condition exists? Surely a condition can't be declared until you know it exists. There's no point in any of us insuring on that basis? Are we all expected to say 'well one day he may get cancer or develop cataracts' when we ask for a quote? It's mind-boggling.

DullGreyGuy

sarahlynnesmith said:

dull grey guy - if the conditions don't have symptoms how is anyone supposed to know the condition exists? Surely a condition can't be declared until you know it exists. There's no point in any of us insuring on that basis? Are we all expected to say 'well one day he may get cancer or develop cataracts' when we ask for a quote? It's mind-boggling.

Most have blanket exclusions for pre-existing conditions and so declaration is a rather moot exercise anyway

Assuming I have found the right policy it appears the definition in this policy is:

Pre-existing condition
Any illness or injury or complication directly resulting from an injury or illness, whether diagnosed or undiagnosed that has been identified or investigated by a vet or is otherwise known to you prior to the start of the insurance or within the first 14 days of the policy for illness or 48 hours in the case of an injury.

So an asymptomatic condition would be covered by this policy as long as no symptoms started in the first 14 days of the policy.

What date/time did you buy the policy?
What date/time did you find "howling in agony"?

You say it was day 16 when the diagnosis was but its when the symptoms first presented that will matter. 

sarahlynnesmith

dullgreyguy - start date of policy was 29th August, found in agony on evening of 13th September taken to out of hours local vet where he spent the night, referred to hospital near Bristol as an emergency on 14th. MRI and diagnosed 15th, biopsy/surgery 16th, euthanasia 19th. The dates are etched on my mind as we are still in pieces over it all.

sarahlynnesmith

sarahlynnesmith said:

dullgreyguy - start date of policy was 29th August, found in agony on evening of 13th September taken to out of hours local vet where he spent the night, referred to hospital near Bristol as an emergency on 14th. MRI and diagnosed 15th, biopsy/surgery 16th, euthanasia 19th. The dates are etched on my mind as we are still in pieces over it all.

dullgreyguy - date of purchase of the policy was 24th August. 

elsien

When you took the policy out, (and you may need to check this by doing a dummy run), what questions were you asked about previous illnesses or injuries? 

The reason I’m asking is that mine having a bit of an undiagnosed limp when I took the insurance out led to a complete exclusion on various conditions being put on the policy. So the insurer may try to argue that you should’ve informed them about the Vet visit when you took the policy out even though you didn’t think it was anything major. 

Whether that is reasonable or not and whether it’s something you can complain about will really depend on the wording of what you were asked when you took the policy out. Plus the specialist vets opinion as to how reasonable it would be to expect that  the two conditions could be related,  if they’re willing to go that far which they may or may not be.

So does the insurer ask about any recent illnesses or injuries when you take the policy out? If no, that’s going to be an easier argument to win. And if you reach deadlock with the insurer, you can always take it further to the ombudsman.

I am very sorry though about your dog. No one expects that when they are so young.