Insurance Claim Dispute - where do I go from here?

SWadventurer

I’m seeking advice on an insurance claim issue. Two years ago, I took out Lifetime premium insurance for my dog with Napo Pet Insurance. Last year, she was diagnosed with arthritis (a new condition), and while Napo paid part of the claim for her x-rays and medication at the time, they’ve now denied a claim for her ongoing medication for her arthritis. Despite referencing my lifetime policy, which I believe covers this, Napo refused to pay and suggested I contact the Financial Ombudsman if dissatisfied. With my policy renewal approaching, I feel frustrated and suspicious of their timing. Any advice on next steps?

visidigi

Only the terms and conditions provided to you at policy creation and then at renewal will be relevant here. You need to check these carefully.

Aylesbury_Duck

SWadventurer said:

I’m seeking advice on an insurance claim issue. Two years ago, I took out Lifetime premium insurance for my dog with Napo Pet Insurance. Last year, she was diagnosed with arthritis (a new condition), and while Napo paid part of the claim for her x-rays and medication at the time, they’ve now denied a claim for her ongoing medication for her arthritis. Despite referencing my lifetime policy, which I believe covers this, Napo refused to pay and suggested I contact the Financial Ombudsman if dissatisfied. With my policy renewal approaching, I feel frustrated and suspicious of their timing. Any advice on next steps?

Are you confident you're right?  Napo must be confident in their position if they're referred you to the ombudsman.

My advice would be to read and re-read your policy.  If you're certain that the ongoing medication should be covered by the policy, then go to the ombudsman and if you're right, it will get sorted out.

SWadventurer

Aylesbury_Duck said:

SWadventurer said:

I’m seeking advice on an insurance claim issue. Two years ago, I took out Lifetime premium insurance for my dog with Napo Pet Insurance. Last year, she was diagnosed with arthritis (a new condition), and while Napo paid part of the claim for her x-rays and medication at the time, they’ve now denied a claim for her ongoing medication for her arthritis. Despite referencing my lifetime policy, which I believe covers this, Napo refused to pay and suggested I contact the Financial Ombudsman if dissatisfied. With my policy renewal approaching, I feel frustrated and suspicious of their timing. Any advice on next steps?

Are you confident you're right?  Napo must be confident in their position if they're referred you to the ombudsman.

My advice would be to read and re-read your policy.  If you're certain that the ongoing medication should be covered by the policy, then go to the ombudsman and if you're right, it will get sorted out.

Thank you for your response. I have re-read the policy which defines "treatment" to include prescribed medications, which should cover ongoing medication for conditions diagnosed during the policy year (in this case, arthritis). Additionally, there's a section of the policy that states that Napo "covers treatment for illnesses or injuries occurring within the policy year, including medications prescribed by a vet". I guess Napo must seem confident to ask me to write to the FOS, but I've also sent the wording on the policy so I'll just have to wait for a response. 

Aylesbury_Duck

SWadventurer said:

Aylesbury_Duck said:

SWadventurer said:

I’m seeking advice on an insurance claim issue. Two years ago, I took out Lifetime premium insurance for my dog with Napo Pet Insurance. Last year, she was diagnosed with arthritis (a new condition), and while Napo paid part of the claim for her x-rays and medication at the time, they’ve now denied a claim for her ongoing medication for her arthritis. Despite referencing my lifetime policy, which I believe covers this, Napo refused to pay and suggested I contact the Financial Ombudsman if dissatisfied. With my policy renewal approaching, I feel frustrated and suspicious of their timing. Any advice on next steps?

Are you confident you're right?  Napo must be confident in their position if they're referred you to the ombudsman.

My advice would be to read and re-read your policy.  If you're certain that the ongoing medication should be covered by the policy, then go to the ombudsman and if you're right, it will get sorted out.

Thank you for your response. I have re-read the policy which defines "treatment" to include prescribed medications, which should cover ongoing medication for conditions diagnosed during the policy year (in this case, arthritis). Additionally, there's a section of the policy that states that Napo "covers treatment for illnesses or injuries occurring within the policy year, including medications prescribed by a vet". I guess Napo must seem confident to ask me to write to the FOS, but I've also sent the wording on the policy so I'll just have to wait for a response. 

That sounds like it should be covered, but I wonder if the timing is the problem here?  "Diagnosed during the policy year" may mean that they're saying that she was diagnosed last year and that ongoing cover only lasted until the end of that policy year.  Once renewed, it's a new policy and the arthritis is considered a pre-existing condition.

What does "lifetime premium insurance" actually mean?  When I first read it, I thought you would have paid an up-front sum for cover for the life of your dog, but you talk about policy renewal, which suggests an annual policy.

eddddy

Aylesbury_Duck said:

Are you confident you're right?  Napo must be confident in their position if they're referred you to the ombudsman.

If you make a complaint to a regulated financial institution, and they reject the complaint - it's a regulatory requirement that they tell you that you can contact the ombudsman to challenge their decision.

I suspect it might be the same if they reject a claim.

So rather than being an indication of confidence, it's likely that they are just doing what the rules require them to do.

DullGreyGuy

SWadventurer said:

I’m seeking advice on an insurance claim issue. Two years ago, I took out Lifetime premium insurance for my dog with Napo Pet Insurance. Last year, she was diagnosed with arthritis (a new condition), and while Napo paid part of the claim for her x-rays and medication at the time, they’ve now denied a claim for her ongoing medication for her arthritis. Despite referencing my lifetime policy, which I believe covers this, Napo refused to pay and suggested I contact the Financial Ombudsman if dissatisfied. With my policy renewal approaching, I feel frustrated and suspicious of their timing. Any advice on next steps?

On what grounds did they refuse the claim?

eddddy said:

Aylesbury_Duck said:

Are you confident you're right?  Napo must be confident in their position if they're referred you to the ombudsman.

If you make a complaint to a regulated financial institution, and they reject the complaint - it's a regulatory requirement that they tell you that you can contact the ombudsman to challenge their decision.

I suspect it might be the same if they reject a claim.

So rather than being an indication of confidence, it's likely that they are just doing what the rules require them to do.

Only complaints but it sounds like they've treated the OPs dissatisfaction as a complaint hence have sent a final response and highlighted the ombudsman service as required

SWadventurer

Aylesbury_Duck said:

SWadventurer said:

Aylesbury_Duck said:

SWadventurer said:

I’m seeking advice on an insurance claim issue. Two years ago, I took out Lifetime premium insurance for my dog with Napo Pet Insurance. Last year, she was diagnosed with arthritis (a new condition), and while Napo paid part of the claim for her x-rays and medication at the time, they’ve now denied a claim for her ongoing medication for her arthritis. Despite referencing my lifetime policy, which I believe covers this, Napo refused to pay and suggested I contact the Financial Ombudsman if dissatisfied. With my policy renewal approaching, I feel frustrated and suspicious of their timing. Any advice on next steps?

Are you confident you're right?  Napo must be confident in their position if they're referred you to the ombudsman.

My advice would be to read and re-read your policy.  If you're certain that the ongoing medication should be covered by the policy, then go to the ombudsman and if you're right, it will get sorted out.

Thank you for your response. I have re-read the policy which defines "treatment" to include prescribed medications, which should cover ongoing medication for conditions diagnosed during the policy year (in this case, arthritis). Additionally, there's a section of the policy that states that Napo "covers treatment for illnesses or injuries occurring within the policy year, including medications prescribed by a vet". I guess Napo must seem confident to ask me to write to the FOS, but I've also sent the wording on the policy so I'll just have to wait for a response. 

That sounds like it should be covered, but I wonder if the timing is the problem here?  "Diagnosed during the policy year" may mean that they're saying that she was diagnosed last year and that ongoing cover only lasted until the end of that policy year.  Once renewed, it's a new policy and the arthritis is considered a pre-existing condition.

What does "lifetime premium insurance" actually mean?  When I first read it, I thought you would have paid an up-front sum for cover for the life of your dog, but you talk about policy renewal, which suggests an annual policy.

She was diagnosed last February, so it's within the current policy year. They have only agreed to reimburse for medication for up to 3 months post her arthritis diagnosis in February. However, the policy states that medication prescribed for her condition will be covered for life - a lifetime policy means that once the insurer has approved a condition (which they did), they'll keep covering it for as long as I'm continuously insured with them, even for my pet's entire lifetime (wording taken from their emails).

born_again

SWadventurer said:

I’m seeking advice on an insurance claim issue. Two years ago, I took out Lifetime premium insurance for my dog with Napo Pet Insurance. Last year, she was diagnosed with arthritis (a new condition), and while Napo paid part of the claim for her x-rays and medication at the time, they’ve now denied a claim for her ongoing medication for her arthritis. Despite referencing my lifetime policy, which I believe covers this, Napo refused to pay and suggested I contact the Financial Ombudsman if dissatisfied. With my policy renewal approaching, I feel frustrated and suspicious of their timing. Any advice on next steps?

Have you received a final response from them on your complaint?


https://www.napo.pet/policy-docs/15/wording

They seem to mention "Up to Limit"

Section 1: Veterinary Treatment 1.1 Veterinary Treatment for Accidents and Illnesses The cover limit for this section is £4,000, £8,000, £12,000 or £16,000 per policy year which is included within your maximum benefit limit. In the event your pet suffers from an illness or injury and needs treatment, we will pay up to the maximum benefit limit per policy year for treatment recommended and carried out by a vet. 

Although further down they do mention Page 27. 
But again has the Up To Limit.

Ongoing illnesses
 ● Accidents that occur in the first 24 hours of your policy start date with Napo. ● Any other claims that occur in the first 10 days of your policy start date with Napo. ● Any injuries, illnesses or behavioural disorders that your pet showed symptoms of, received treatment, medication or advice for in the 24 months before taking out your first policy with us. Provided you remain continuously insured with Napo, and your premium payments are up-to-date, we will cover your pet for any illnesses or injuries that arise during your insurance with us regardless of whether they first occurred in an earlier policy year, at all times up to the policy maximum benefit limit

sheramber

Napro state

We have four different levels of cover to choose from. That means you can choose the maximum vet fees per year you’d like to be covered for, and pick cover that’s right for you and your pet.

What level of cover did you choose?

Have you used up the level  of vet fees this year?

If that is the case then that amount should be reinstated when you renew the policy.

SWadventurer

visidigi said:

Only the terms and conditions provided to you at policy creation and then at renewal will be relevant here. You need to check these carefully.

Thank you. I have checked the wording on my existing policy and the renewal policy. The wording is quite clear as follows: "includes prescribed medications, which should cover ongoing medication for conditions diagnosed during the policy year".