Insurance claim issue

[Michen]

Brief background, horse diagnosed with ligament injury in feb. No reaction to flexion and lameness only seen when worked hard and jumped (disuniting over a fence). Injury rehabbed and horse sound. Horse goes lame again (now positive to flexon and lame in both legs) and diagnosed with spavin.

Can someone please help me unpick exactly what this means:

For the purposes of this section, the following will be treated as one claim:

lameness of any limb or symptoms reported to US that are subsequently diagnosed as lameness
of one or more limbs caused by separate injuries or illnesses;

I am struggling to understand what it even means? The insurance company are trying to put a claim for hock arthiritis (diagnosed 4 months after original ligament injury), through as part of the same claim. My vet is thoroughly on my side, as the hocks were diagnosed 4 months ish later from a positive flexion etc- something he never had when diagnosed with the ligament injury. Although the above bit is in my policy and I'm trying to understand it, the insurance have said this bit is why they are saying it's one claim:

All veterinary fees, in the case of a chronic or recurring CONDITION or a CONDITION that appears to have or has multiple causes, or complications arising from the CONDITION, relating to that CONDITION falling within the terms and conditions of this Certificate shall be considered as one CONDITION, and limited to the MAXIMUM BENEFIT for that CONDITION.

So I would hope that given they are completely unrelated, and not due to a complication and not apparently when initial issue diagnosed, that I should be able to fight this?

It's not the end of the world but annoying as it will leave me with a 2/3k bill!

 

[ihatework]

I don’t know, it would be worth a phone call. That sentence is gibberish.

It’s becoming more common for insurance companies to try and lump incidents together under one claim. KBIS are getting pretty hot on it, especially for ulcers combined with orthopaedic. I kind of understand why.

In your case, whilst the symptoms of hock arthritis may have become noticeable due to the lack of mobility due to ligament treatment, I think it’s thin ice to suggest the arthritis had a direct link. My guess is you could argue the arthritis was already there but undetected.

Worth a challenge at the very least

 

[Michen]

I don’t know, it would be worth a phone call. That sentence is gibberish.

It’s becoming more common for insurance companies to try and lump incidents together under one claim. KBIS are getting pretty hot on it, especially for ulcers combined with orthopaedic. I kind of understand why.

In your case, whilst the symptoms of hock arthritis may have become noticeable due to the lack of mobility due to ligament treatment, I think it’s thin ice to suggest the arthritis had a direct link. My guess is you could argue the arthritis was already there but undetected.

Worth a challenge at the very least

I'm so glad you thought so too. I re read it 10 times and thought I was going mad not to understand it. It makes no sense! I thought it was perhaps saying that any further lameness in a limb would be put under one claim whether related or not.

I can totally see why as well, if we had done a poor performance work up and found multiple issues. But we found one issue in a sound (on flexion and trot up) horse, and the blocks confirm that the lameness now is a newly apparent hock issue.

 

[Red-1]

Yes, I read the first bit that once a leg has had a lameness, then any other lameness in the same leg is considered to be the same claim. In fact, it seems to include lameness in a different leg too That seems a bit silly.

The second paragraph seems a bot more sensible and links associated conditions.

TBH, when I claimed for Jay, he had a mild suspensory injury and when he was rested for that he lost body tone, sagged, and then became a wobbler. I would have thought a front suspensory, that was minor and healed perfectly well, would have been a separate claim, but they insisted not.

However, I had a £500 excess, and we didn't go over my limit, so they only cheated themselves there!

Which company is it, as the first paragraph doesn't seem fair at all.

 

[Michen]

Yes, I read the first bit that once a leg has had a lameness, then any other lameness in the same leg is considered to be the same claim. In fact, it seems to include lameness in a different leg too That seems a bit silly.

The second paragraph seems a bot more sensible and links associated conditions.

TBH, when I claimed for Jay, he had a mild suspensory injury and when he was rested for that he lost body tone, sagged, and then became a wobbler. I would have thought a front suspensory, that was minor and healed perfectly well, would have been a separate claim, but they insisted not.

However, I had a £500 excess, and we didn't go over my limit, so they only cheated themselves there!

Which company is it, as the first paragraph doesn't seem fair at all.

Shearwater but they've just re sent me my policy, which doesn't have that wording in it (seems they sent the wrong pdf in march) it only has the later which they referred to in email:

All veterinary fees, in the case of a chronic or recurring CONDITION or a CONDITION that appears to have or has multiple causes, or complications arising from the CONDITION, relating to that CONDITION falling within the terms and conditions of this Certificate shall be considered as one CONDITION, and limited to the MAXIMUM BENEFIT for that CONDITION.

This is good news I think as the above is more easily contested. They define a condition as "
CONDITION means any INJURY, or any related
manifestation of a LAMENESS or ILLNESS. Note: a
CONDITION that appears to have or has multiple
causes, or complications will be considered as a single
CONDITION. This is also an undefined term, only
where the word is in capital letters will this definition
apply."


Well, I think you'd be hard pushed to prove that the spavin was related as the horse in May was rehabbed, sound, scanned and signed off. Then went lame again. In BOTH hocks....

I will absolutely fight this, I just hope it's not fruitless.

 

[Red-1]

Shearwater but they've just re sent me my policy, which doesn't have that wording in it (seems they sent the wrong pdf in march) it only has the later which they referred to in email:

All veterinary fees, in the case of a chronic or recurring CONDITION or a CONDITION that appears to have or has multiple causes, or complications arising from the CONDITION, relating to that CONDITION falling within the terms and conditions of this Certificate shall be considered as one CONDITION, and limited to the MAXIMUM BENEFIT for that CONDITION.

This is good news I think as the above is more easily contested. They define a condition as "
CONDITION means any INJURY, or any related
manifestation of a LAMENESS or ILLNESS. Note: a
CONDITION that appears to have or has multiple
causes, or complications will be considered as a single
CONDITION. This is also an undefined term, only
where the word is in capital letters will this definition
apply."


Well, I think you'd be hard pushed to prove that the spavin was related as the horse in May was rehabbed, sound, scanned and signed off. Then went lame again. In BOTH hocks....

I will absolutely fight this, I just hope it's not fruitless.

Ha, I don't think they can get away with sending one set of policy documents at the start, then send different ones when you claim, claiming that the first ones were 'wrong'. I think you will win that one!!! Good luck!

 

[Michen]

Ha, I don't think they can get away with sending one set of policy documents at the start, then send different ones when you claim, claiming that the first ones were 'wrong'. I think you will win that one!!! Good luck!

No the new policy docs (correct ones) work in my favour I think. As it only has that one paragraph not that weird vague sentence that seems to say any lameness in same limb is one claim regardless.

 

[GoldenWillow]

That first sentence in first post makes no sense at all to me. The second one about CONDITION appears at first reads simpler and you should be OK, but, then I read it again and I'm not so sure now. It appears that they are saying (again) that lameness that has multiple causes is one condition. I think it is a disgrace if that is what they are trying to do and hope I've just read it the wrong way although to my mind insurance T&C should not be ambiguous. I really hope you are successful in getting it put through as two separate claims as they should be.

 

[Michen]

That first sentence in first post makes no sense at all to me. The second one about CONDITION appears at first reads simpler and you should be OK, but, then I read it again and I'm not so sure now. It appears that they are saying (again) that lameness that has multiple causes is one condition. I think it is a disgrace if that is what they are trying to do and hope I've just read it the wrong way although to my mind insurance T&C should not be ambiguous. I really hope you are successful in getting it put through as two separate claims as they should be.

Thanks. I did the same when reading it! It'll be interesting to see how they can argue it particularly as he's now lame in the left hock too... how can that be one condition!

 

[Muddywellies]

Always best to get it from the horse's mouth (pun intended ?). Insurers are perfectly approachable and its always best to direct any queries directly to them. Insurance is never easy to read unfortunately. Why use 5 words when 97 will do?

 

[Michen]

Always best to get it from the horse's mouth (pun intended ?). Insurers are perfectly approachable and its always best to direct any queries directly to them. Insurance is never easy to read unfortunately. Why use 5 words when 97 will do?

Of course I have- that's what they came back with.

 

[ester]

I *think* it's worded to try and include supporting limb issues being part of the same claim.

 

[ycbm]

I *think* it's worded to try and include supporting limb issues being part of the same claim.

This would be fair enough. It's known, for example, that the opposite foot can develop laminitis if a horse is non weight bearing for too long on a lame leg.

I wouldn't accept that for bilateral spavin, Michen, and I think you've got a good case if you go to the ombudsman.

Good luck!

 

[Annagain]

The only link I could see is that the reduced mobility from the box rest could have given rise to the spavin and therefore, although they are two separate instances of lameness, they're related? It doesn't seem fair but I wouldn't put it past an insurance company.

 

[jnb]

I would suggest you report to the insurance ombudsman (or threaten to!! as this smacks of them moving the goalposts, their fault entirely they sent the wrong pdf and you have a get out of jail card right there
However these are 2 separate claims, front leg & front legs yes I can see they’re related. But front leg - rehab - sound - hind lameness are completely unrelated.
good luck

 

[SusieT]

Am I not right in saying your vet said the hock problems were due to the box rest in which case there may be a link? I'm guessing also as he is lame , they are saying the diagnosis of lameness has multiple factors which may be why?

 

[Michen]

Am I not right in saying your vet said the hock problems were due to the box rest in which case there may be a link? I'm guessing also as he is lame , they are saying the diagnosis of lameness has multiple factors which may be why?

It was simply a musing from the vet that it could be lack of mobility. No one really knows.

The point is it wasn’t there/found in initial diagnostics. And he was sound post rehab before then going lame with the spavin.

 

[Michen]

I would suggest you report to the insurance ombudsman (or threaten to!! as this smacks of them moving the goalposts, their fault entirely they sent the wrong pdf and you have a get out of jail card right there
However these are 2 separate claims, front leg & front legs yes I can see they’re related. But front leg - rehab - sound - hind lameness are completely unrelated.
good luck

It was right hind the ligament. And right and left hind the spavin.

 

[Michen]

The only link I could see is that the reduced mobility from the box rest could have given rise to the spavin and therefore, although they are two separate instances of lameness, they're related? It doesn't seem fair but I wouldn't put it past an insurance company.

Yep but I don’t see how they could possibly prove that. Especially given there was a period where he was sound post rehab pre new lameness.

 

[Muddywellies]

Of course I have- that's what they came back with.

Just give them a tinkle and ask them to explain for you. I worked for many years in insurance (not equine) and its totally normal to explain things to customers in a way that they will understand. (insurance can be a bit mind boggling at times). It really is best that they explain this to you, and that you're satisfied that you understand, even if they have to explain it two of three times.

 

[Boulty]

Insurance companies are weird... Twice I've been utterly convinced I'd not a cats chance in hell of a payout (the second time in particular I only put a claim in on the offchance) & then been a bit baffled to receive a cheque. Anyway I'd definitely fight it & refer to ombudsman if needed

 

[Annagain]

Insurance companies are weird... Twice I've been utterly convinced I'd not a cats chance in hell of a payout (the second time in particular I only put a claim in on the offchance) & then been a bit baffled to receive a cheque. Anyway I'd definitely fight it & refer to ombudsman if needed

A similar thing happened to me with my dog. We lost him to an accident at the yard, I rushed him to the vet but they couldn't save him. He wasn't insured for death but I put in a claim for the emergency treatment as it was quite expensive. They paid for the treatment, his cremation and compensation for death and sent a very lovely letter apologising for me having to pay the excess! I have no idea why, I never asked.

It made up for a claim they ruled out for Archie for his melanomas. His started inside his sheath so by the time we found them they were quite big. They wouldn't pay for a biopsy to make sure they were melanomas (if they were carcinoma treatment would have been very different) because they were of a size that meant they must have been pre-existing.