Pet insurance company claims it is illness and my vet surgeon it might be accident

mariobres

mariobres

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Hi,

My dog is insured with "accident only" insurance coverage.

"We can see that you are claiming for treatment for Left Hind Lameness and TPLO surgery. As per the
clinical notes from your vet on 15/03/23 “Lameness LH intermittent” Then on 16/08/23 “History of LH
lameness since March. Started to be intermittent but it's constant at the moment. Toe touching and
avoiding to put weight on the LH”.
As your policy is Accident Only Cover, this is not covered under your policy
Please see your Terms and Conditions under Definitions:
“Accident - A sudden unforeseen and unintended Event causing Injury to Your Pet”
“Illness - Any sickness, disease or changes to Your Pet’s normal healthy state.”

Vet / surgeon have different oppinion:
"I would challenge the insurance company to produce a definition of what is an accident? I cannot confirm or deny that Melody did not have an accident/trauma when off lead or playing back in March which triggered the lameness. At the time of surgery I confirmed that there was a cruciate ligament tear but I cannot prove definitively what the underlying cause was.

In my opinion, there are canine patients who can injure/tear their cruciate ligament via a trauma/accident which can start as an intermittent lameness and progress. Equally there are many patients who have a degenerative injury resulting in a progressive lameness. "


Do you think I have the case against Insurance company?
Do I have even a slightest chance to go through Small Claims Court?

Kind regards and thanks to all who will reply,
Mario
 
Hi Mario

1) Send the vet's report to the insurance company and say to them "If you do not agree to settle my claim in full, please state so and say that this is your final response so that I can complain to the Financial Services Ombudsman".

2) If they don't settle it or offer you a reasonable sum, then make a complaint to the Ombudsman.

3) The Ombudsman will probably resolve it at mediation stage.

Brendan
 
Hi,

Have had two dogs needing cruciate operations as a result of injury. Before they try either of the surgical options available they will generally give the dog an anti-inflammatory to see if there is just a soft tissue injury. Rest and medication may work which was probably the procedure that your vet attempted before putting the poor dog through possible unnecessary surgery.

IMHO this is the insurance company chancing their arm to avoid paying for the expensive surgery.

Our insurance is with Allianz who did not try to dispute our claims and one was particularly expensive. I understand they employ vets/vet nurses to help with the claims.

I have also heard from many vets that they are the best to deal with and some of the other companies will try to avoid payment by using the small print.

As Brendan says above fight it. The wording from your vet appears to support your claim.
 
I think the challenge here will be in proving there was an insurable event. Without evidence of an accident, you can't prove this is a covered event. The vet's wording does not help your case.
 
Yeah Leo, I think also that Vet's wording is not really strong enough. I would expect something like - she is too young to develop illness or similar... But, he is giving room to this interpretation.
 
mariobres said:
I would expect something like - she is too young to develop illness or similar... But, he is giving room to this interpretation.
Click to expand...
In the vet's defence, they are stating all they can say. So long as there is even a minute chance of the cause being anything other than an accident, they cannot confirm the cause. To sign a declaration as to the cause for insurance purposes without absolute certainty could leave them open to fraud charges.
 
Some general principles ;

1. The onus of proof rests on a policyholder to establish that an insured peril has occurred.
2. The standard of proof would be the balance of probabilities.
3. Balance of probabilities means that something is at least 51% more likely than not.
4. In summary, the policyholder has to establish, on the balance of probabilities, that the proximate cause was an accidental injury.
5. Proximate cause means the active efficient cause that sets in motion a train of events resulting in a particular occurrence.
6. The insurers have actually created the contractual definition of what they mean by "accident" as per post #1.
7. Check the contract wording to see what provision there is for dispute resolution. Some insurance contracts may not be within the Ombudsman's
remit or you may be obliged to submit to arbitration.

The policyholder has to show, on the evidence, that an insured event has happened.
The veterinary evidence is weak as it is ambiguous.
Evidence consistent with an assertion is not adequate proof either.

You would need a vet to be able to say that, in their professional opinion, the injury could only have been caused, as a matter of probability, by an accident. The vet is being honest in their opinion.
A second opinion, to the contrary, might be required.

Sorry if this is unhelpful. You can still push this a bit further without risk of legal costs.
 
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