Pet insurance payout refusal

designeditdesignedit

hello, i will try to keep this is brief as possible...
my daughter has a JRT and he is insured with Petwise. He is eight years old, had an undescended testicle. Recently we noticed he was undwell, took him to the vet who said he needed emergency surgery as she could feel a lump. It seems the undescended testicle had turned cancerous and a tumour was removed. Petwise refused to pay it as the vet had initially described this as a castration and also (this is what seems to be causing the refusal to pay) had included the word 'routinely'.... However, what they MEANT was everything went routinely i.e. no problems. 
Petwise said they won't pay out as it was a routine castration. 
The vets have emailed them again saying it was emergency surgery for a tumour, where the tsstice was found to be cancerous.

Petwise are saying that the case is now closed. 

My daughter works as an animal care assistant at an emergency vet - this is extremely awkward as the vets she works with are locums and also work at the vets where the operation took place. There is an outstanding bill of around 5k. The paperwork she has from when she started the polciy a few years ago states they will pay out on tumours but not pre-planned castrations. This is not a preplanned castration it was emergency surgery to remove a tumour.

She has contacted them again and has been informed she needs to complain to 'insurance factory;. - we dont know who this Insurance Factory are.

Is this something an ombudsman could help with? This is very stressful due to her work situation and also she is racking her brains trying to think how to raise 5K.... thats not an option - she wouldn't be eligible for a loan either. 

Any advice would be appreciated.

DullGreyGuy

Was the undescended issue declared when she took the policy out? Did the insurer confirm they'd cover it/anything related to it?
Has the vet commented on if the issue is related to the fact they were undescended or it's just coincidental?

Ultimately you need to put in a complaint to the insurer, if you are unhappy with their response (or they dont respond within 8 weeks) then you can escalate the matter to the Ombudsman. 

elsien

Yes, she needs to go through the insurance complaints procedure first. 

In the meantime would the veterinary practice, agree to a payment plan for amounts that she can afford?

Insurance factory is the email address for complaints btw. Or she can write or do it online.
https://www.petwise-insurance.com/existing-customers/complaints/

designeditdesignedit

Thank you for yoru replies. The undescended has been mentioned each year at his check up/vaccination although it's just something teyve noted , not advised any action. Vet hasnt commented if the issue is related or not. 

Luckily, the vets are being quite patient and as yet havent requested a payment plan but thats something we need to consider..

I will initiate the complaint today.

TELLIT01

Undescended testicle won't normally require treatment which will be why the vet mentioned it but didn't advise any action.  Our dog had the same condition but it never caused any problem

DullGreyGuy

designeditdesignedit said:

Thank you for yoru replies. The undescended has been mentioned each year at his check up/vaccination although it's just something teyve noted , not advised any action. Vet hasnt commented if the issue is related or not. 

But had she declared it as a condition to the insurers or not? If so had it been accepted as an insured issue or not?

The problem with conditions is that the exclusion will say "or related conditions" and so if she's failed to declare it that results in an almost blanket exclusion on something impacting the same body part. 

designeditdesignedit

no, not declared as a condition. Had the vet mentioned on check ups that it migjht be classed a conidition she woul have declared it. It was just noted, as was the odd dew claw on hind leg.

designeditdesignedit

Just to update, the insurance company did pay the bill eventually.

elsien

Well done. Did it take the complaint or did you manage to resolve it without that?