Insurance problem

[Izzwall]

Hey all, it takes me a lot of courage to post on here so here goes!

Right just a bit of history, I insured my boy last year (won't say which insurance company it is but can PM anybody who is interested) for category 2 which involves hacking, rides up to 25km and western riding, had a look at category 3 when taking out my policy but it was competition work and I don't compete. Well anyway, I backed and broke in my boy myself and mainly hacked around the farm, didn't do hardly any schooling and taught most of his ridden work when hacking about which he picked up very quickly. I then had a very unfortunate accident on him where he spooked at something and I came off and broke my elbow (this was last July), so had to turn him away till I healed. Even more unfortunate the moment my elbow healed I fell out my conservatory and broke my ankle, when that finally healed I fell over at work and very badly broke my ribs which I'm still recovering from so all this time my boy had been turned away to grass. During around the start of march I started to notice something wasn't right with my horse, he was tripping a lot, tilted his head, started head pressing and generally looked a very unhappy horse and wasn't the cuddly, happy boy he usually is. I got his eyes checked by a specialist, all was fine and then started having the vet out in which I got hold of my insurance company stating what was happening and I will need to make a claim in which they replied that was fine.
Vet came out, he failed the neurological tests so proceeded to take bloods and then xrays. Claim form was sent off and everything was ok so proceeded with the xrays once the blood test came clear where we discovered significant arthritic changes in the C6/C7 vertebrae and something 'very concerning' involving his cervical vertebrae by his poll so the vet took more xrays of that area to take a closer look. In the mean time my boy was rapidly going down hill every week and was no longer the horse I got to know and love. I requested some bute and the difference was astonishing to his mood but not his neurological problems and is currently on 4 sachets a day.
However, in the last two weeks my horse has gotten even worse, cannot canter anymore, cannot back up and I've seen him struggle to get up too which is soul destroying to witness. Also in the last 3 days he's drinking about a 1/5 of what he usually drinks and looks very depressed. The vets still aren't sure what's wrong with him even though I think it's wobblers and so does one of the vets (they said 90% sure) and he might have a rare form where it causes a lot of pain. I've wanted to put him to sleep weeks a go and I'm so worried I'm going to find him on the floor unable to get up. But the vets still want to investigate for insurance reasons to 100% diagnose what the problem is.
Yesterday I got a letter from my insurance company stating they have rejected my claim and will not take it further. I rang them up and they said I'm in the wrong category stating that I should of been in category 3 as that includes breaking and backing. But trying to remember now it did not say backing and breaking under category 3 though checking now they have changed the layout and have included it. I said that he's been turned away for the last 10 months and did not do any sort of schooling. They turned around and said I might of caused whatever Rambo's suffering from due to me breaking him in and are refusing to pay out.
The vet bill is in the thousands and I'm panicking. I lost my job earlier in the year due to slipping over at work and had to claim compensation (still ongoing and not received a penny yet) and in all honesty I have very very little money to my name right now. My vets are kindly going to have a word with my insurance company to see what they can do but is there anything to change their minds? If they won't pay out I want my boy pts as soon as possible before he gets even worse but if they agree to pay out I have to keep him alive for more tests (the consultant who saw his xrays wants to come down and see him). Not only am I devastated I'm about to lose my beloved horse but I'm also worrying myself sick about how the hell I'm going to pay all these vet bills. If my insurance company had stated from the beginning they would not pay out I would never of put Rambo through all this just to find a diagnosis.
Chocolate fingers for anyone who got to the bottom of that! Thanks

 

[JillA]

From a quick read of your post I get the impression he is broken and turned away - how can they say he is still in the breaking stage? There is an insurance ombudsman, which seems to be part of the Financial Ombudsman service http://fos.org.au/centric/home_page.jsp.
Have you got the full terms and conditions of your policy, what does it say in there? Regardless of whether they have changed it since, their contract with you is set out in there unless they have notified you of changes when you renewed it.
*sigh* Small print, I know, we outdoors types hate it with a passion!

 

[Izzwall]

When I sent my claim form I read all the T&Cs just to make sure and I didn't see anywhere saying 'not covered for newly broken horses', I took out the insurance policy just after I broke him in and began hacking him around hence why I picked category 2. Not sure if this year could get any worse

 

[JillA]

In that case I would be referring it to the Ombudsman. You could always give the company one last chance to do the right thing before you do, and tell them that will be your next course of action. I think a lot of these companies do try it on, to see if they can get away with it and save themselves a lot of money. Good luck.

 

[Mardy Mare]

Aww how stressfull for you and what a unlucky year you have had. I would try not to panic just yet.

I'm not that knowledgeable enough when it comes to insurance claims but surely if after final tests are done and it is wobblers syndrome, this cannot be attributed to any sort of riding can it? So wouldn't they have to pay out?

Also, did you take the name of the call service staff who from what I can make out, said what you intended to claim for was fine?

Looks like they're just trying to crawl out of paying up.

Good luck.

 

[undergroundoli]

God, I don't have any thing helpful to say but I just want to tell you I'm sorry

 

[MrsNorris]

What an horrific situation to be in, so sorry for you both, nothing helpful to say, just good luck and I hope you get it sorted quickly.

 

[AmyMay]

If they won't pay out I want my boy pts as soon as possible before he gets even worse but if they agree to pay out I have to keep him alive for more tests

Just going to pick up on this point.

You don't have to keep him alive for more tests, and it does sound as if pts is the best option.

Good luck with the insurance company.

 

[Izzwall]

Just going to pick up on this point.

You don't have to keep him alive for more tests, and it does sound as if pts is the best option.

Good luck with the insurance company.

My vet told me I have to due to the consultant coming down next week (I've postponed it in case my insurance company doesn't pay out and I'm left with more bills) as he wants to see the extent of my horse's neurological problems. Though I have now taken videos of him not being able to canter properly and also him not being able to back up. I've sent them to my vet so I'm hoping that'll be enough for the consultant to see. Not only that but I also owe my livery a lot of money due to when I had all my injuries my boss at work gave me no sick pay so all my savings I had put away to help me out in this sort of dilemma are all gone (almost 2 grand). I was so hoping that I would get some money from loss of use so that could pay off my livery. Thankfully my YO has been so incredibly understanding but I will need to pay it all off before he goes (or shortly after). It's all just one big mess tbh.

 

[Jools2345]

My vet told me I have to due to the consultant coming down next week

why do you have to because the consultant is coming? by law a vet cannot tell you what you 'have to do' they can only give you their educated opinion, the only exception to this is if two vets agree to overide the owners wishes regarding PTS on welfare grounds.

fight the insurance company every step of the way but if you feel your horse is suffering and if it is time to pts tell your vet thats what you want done or your will take them to court for allowing your horse to suffer against your wishes.

 

[Beau jangles]

With every insurance company you have to pressure them , they always try to find a way out of paying , I know I worked or a car insurance company's for a few years !
When my sisters horse broke its leg they said they wouldn't pay out as she had another small injury a cut to another leg 2 weeks before , which has nothing to do with the injury that caused her to be pts.
We phoned the insurance and told them if they didn't get there act together we would be contacting the ombudsman and we had already contacted our own lawyer which we hadn't , but hey presto 2 weeks later cheque arrived !
You just have to take take a firm stance and don't take no for an answer , even better your vet is helping , hopefully you will get the right outcome

 

[AmyMay]

Your horse your decision. Not the vets.

 

[Vanner]

If you go to the ombudsman before allowing the insurer to look into your complaint, the ombudsman will just send them details and not do anything. You need to officially complain in writing to the insurer, under the FOS guidelines they have 8 weeks to investigate the complaint. If you are still not happy with the response then you can ask FOS to look into it for you.

I am going to PM you as well ...

 

[Polos Mum]

OP TBH I would stop all further vet treatment, at best it will be covered by insurance - they aren't talking about finding a treatment or cure for your poor boy, just a diagnosis to keep the insurance company happy. At worst it won't be covered and you'll just have a bigger bill.

If he needs to be PTS, and vets agree - just do that, his welfare needs to come first. Perhaps speak to the insurance company and see if a post mortum (or whatever the proper name of the animal equivalant is!) will be sufficient evidence for them along with the vets opinion.

How did the insurance company know you broke him? Irrelevant now but just interested. I'd just be clear you did break him but before this insurance renewal (ie over 12 months ago now) - what does basic breaking take 4/5 weeks? Yes all the education after that takes years but the actual get a saddle on an do one turn of the school with a rider - just a few week. So the category of use is right in this insurance period that you are making a claim for.

Every insurance company will look for evey excuse to not pay - that is their job - you have to fight and argue - difficult I know when there's a lot on your plate not to mention potentially loosing your boy. Good luck for a nasty situation.

 

[Goldenstar]

You must exhaust all avenues with the insurer before you go to ombudsman .
You must written notes of all conversations from now on and confirm everything with emails .
They will try to get out of any thing they can but if the horse was ridden away when you first insured it I really don't see they have any argument at all.
I think I would email at once with all the details and the time line laid out and say you do not accept you have used the horse in a way not covered you are taking legal advice.
The poor horse this is so sad , there are not many times than a vet can PTS before aggreement from the insurer without breeching the term of the policy your dispute with the insurer makes this worse.
I would talk to the vet as soon as you can and be clear in your mind exactly what's the position with this consultant coming.
You can of course PTS your horse at any time you chose but this will will make it very difficult for your claim you need good advice quick if you are a BHS gold member you could try their legal helpline .
Good luck it's just a horrible situation to be in.

 

[Jools2345]

The poor horse this is so sad , there are not many times than a vet can PTS before aggreement from the insurer without breeching the term of the policy your dispute with the insurer makes this worse.

really? i did not know that. what a shocking thing, i work at a a vets and if an animal needs to be pts then it is and the insurance company are dealt with after.
what happens if it a problem that occurs when insurance company are closed?

will have to ask about this at work

 

[Polos Mum]

To be put to sleep in an emergancy the horse has to meet the very specific BEVA (I think that the right name) criteria - usually if that is the case then there shouldn't be a problem with insurance - the difficulty here is that it isn't an emergancy and wouldn't meet the criteria so not an option for the vets unless he gets much worse.

Very sad but if Jouls you look on here you'll find lots of examples of horses that needed PTS where insurance co refuses and insists on pointless low chance of sucess operations. I am very cynical but I suspect they do this deliberately to avoid paying out as many people just give up on the insurance and do the right thing by their horse (and the companies know that we do this)

 

[Izzwall]

Thanks to everyone for the advice. I'm planning on putting my boy to sleep next friday, even though I most likely will not get anything for loss of use, my boy's welfare means a lot more to me than money!
I'm really also starting to think I've been taken for a 'ride' by my vet as he's the one who's made this all go on a lot more longer (and more expensive) than it should. It's taken so far 10 weeks since I started getting worried about my horse and each week that goes by the vet keeps on coming up with more investigations and so far Rambo's had neurological tests, blood tests, 2 sets of xrays, eye tests and so on. Just thinking surely by now they would know what is going on!! All my vet will tell me is he thinks it's wobblers, it's to do with the vertebrae in his neck and whatever it is is causing arthritis lower down in his neck. But when I say I think it's best we put him to sleep he suddenly says 'well we aren't 100% certain what it is yet and if it could be treated and we need to diagnose for your insurance purposes'.
Starting to think they do know what it is but are just trying to get as much money out of this as possible (I recently learnt one of the vets working with Rambo has a reputation for this).
If the insurance company does not budge even when my vet gives them a ring (the other vet I trust more!) then I'll be sending a complaints letter to the insurance company and see if that'll work.
Such a shame, my boy is only 5

 

[Roasted Chestnuts]

Fight them. I did and finally they paid out. Took me a year though

Write to insurance company stating your clear intentions to take them to the ombudsman, also photocopy the T&C's that were sent to you when you premium was agreed and also the certificate of insurance.

This will all be proof that your insurance was valid when you took it out. I never now take insurance out over the internet. I talk to someone on the phone, making sure I have date and time of the call and the ID and name of the phone rep and it all gets filed with my insurance certificates so I know. i also call them when my renewal letter comes in and I go over it with them before agreeing or cancelling and again i take the above details.

I wont ever be caught out again.

 

[Polos Mum]

Very sad for you and him but well done you for putting his welfare first ahead of the cash.

Sadly it's all too common for vets to suggest expensive and complex investigations once they know insurace is paying, often if the insurance isn't available they recommend time and rest as alternatives. You'll also spot that they know what the insurance limits are and spend quickly up to that before deciding time/ rest is needed !!
I will often tell a vet the horse isn't insured (even if he is) just to get a more balanced view on what treatment is best.

 

[Lola43]

I can totally sympathise, as I have first hand, personal experience of the condition with my last horse and, bizarrely, my current horse. That has turned into a total, uninsured, nightmare. I would pm you, but I don't know how! If you send me a message I would be happy to give you the benefit of my experience.

 

[MagicMelon]

fight the insurance company every step of the way but if you feel your horse is suffering and if it is time to pts tell your vet thats what you want done or your will take them to court for allowing your horse to suffer against your wishes.

This is what I'd do. Horrid situation you're in. I think I would get a second opinion from a different vet. You need to stress to them you will be putting the horse to sleep if a diagnosis (and course of action if there is one) isnt made basically immediately. I'd keep the insurance company up to date with everything. If the vets keep messing about then make the decision. After that then fight the insurance company. Which company are you using?

 

[cyclo man]

Hi sorry to hear of your problems. There is a very clear procedure for this issue. Firstly you will have been sent a full policy document that states exactly what is covered and what is excluded when you purchased the policy, if you have lost this the insurer will provide a copy of the terms at that time. Secondly if the insurer changed the terms of the policy after you took it out they are obliged to give you written notice and time to insure elsewhere if you wish, unless you agreed to accept the change or ignored a notification the original terms apply. Thirdly do not under any circumstance instruct your vet to PTS against their advice, this will invalidate your cover and you will not have legal recourse against the vet or the insurance co. The person that you need to contact in the first instance is the compliance officer of the insurance company who has a legal obligation to deal with and investigate your complaint, write a clear and concise letter stating the facts and exactly what you have been told along with copies of supporting evidence, also if possible get a letter from the vet confirming what they have done. If the issue falls within the cover offered by your policy they will pay out, insurers are highly regulated and will only refuse claims that are not within the scope of the policy, unfortunately all to often people dont pay enough attention to the Terms and Conditions when insuring and then get caught out, in effect you get the cover you pay for. I do hope you are able to sort this out and that you are able to claim.

 

[ladyt25]

Right, firstly I am really sorry to hear about your situation, it does sound like wobblers given his age as well. :-( As for the insurance company this seems very odd indeed. Normally the lowest level of use cover is horses at grass, foals, breaking and backing. The 2nd level includes hacking, dressage etc. Your horse, in my opine would have been in the lowest level of cover and there is no reason why the insurance will not settle the claim BUT you would need a diagnosis from the vet. Of course you can have your horse pts when you feel is necessary but this may not then be claimable on insurance. I worked in horse insurance for many years and they don't try 'get out' of paying. It may seem the case but sadly that's due to the amount of fraudulent claims. However, your situation sounds strange so I would be interested to know who your insurer is as, to me your claim seems pretty straightforward!

 

[smellsofhorse]

Definitely fight them.

I had to.
It took 6 months but they eventually did pay out in full.

I hope you sort it quickly.

 

[flitz02]

Sorry to hear you prob's.My vet had to phone up & almost plead with the insurance company for my mare to be pts.If it is your vets opinion that pts is the kindest option then do get him to phone your insurance company who should have a veterinary advisor who is usually a vet themselves.i have to say i dont insure these days for vets fees because of this.You feel over a barrell that if you go ahead without your insurance co permission they will refuse to pay! Good luck &n fight them all the way sometimes they just try it on to put you off claiming.x

 

[TandD]

sorry to hear of your situation... and i have no help

but does know one (not you op) have any compassion for the horses???
vets want to 'investigate' and not put horse down - they no longer seem to care so much about the welfare of a horse. they can have a look after if the owner agrees!
insurance comps want to keep horse alive for as long as poss...dont know why costs them more in the long run!!!

it is rediculous that horses are treated like this - im sorry op but it sounds like your horse should have been put down much sooner....of course i do understand that you feel under pressure and the vets and insurance company have treated you very badly..plus your awful year!
send hugs your way! and hope everything resolves its self in the end

 

[AmyMay]

I think there is plenty of compassion for horses from vets and insurance companies alike. However what should of happened in this situation is that the vet should have called 'time' weeks ago.

 

[Pearlsasinger]

Just going to pick up on this point.

You don't have to keep him alive for more tests, and it does sound as if pts is the best option.

Good luck with the insurance company.

why do you have to because the consultant is coming? by law a vet cannot tell you what you 'have to do' they can only give you their educated opinion, the only exception to this is if two vets agree to overide the owners wishes regarding PTS on welfare grounds.

fight the insurance company every step of the way but if you feel your horse is suffering and if it is time to pts tell your vet thats what you want done or your will take them to court for allowing your horse to suffer against your wishes.

A friend had a 2 yr old with a nasty colic. She was taken for surgery and deteriorated on the way. The vet said that there was a less than 10% chance of recovery. Friend wanted to pts without surgery but insurance company refused to pay out unless everything possible had been done. It doesn't make sense because it obviously cost them more in the long run. Horse died under anaesthetic and friend claimed.
The only way you can over-ride the insurance company is if you don't claim, which in OPs sitution is hardly an option.
OP tell your insurance company that you will involve the ombudsman, I wouldn't be surprised if they suddenly change their minds about paying.

 

[Izzwall]

Problem I have is is that one vet who saw Rambo right at the beginning and who I managed to talk to right after I was off the phone to the insurance company advised putting him to sleep, especially after telling her he's not drinking properly anymore and his back legs keep giving way. However, the other vet says keep on with the investigation. I now don't care about covering the money to have him pts and loss of use, I just need the vet bills covered as my boys welfare and comfort is so much more important. Just worried that if I do have him pts my insurance company have another excuse not to pay out.