OCD - insurance refusing to pay to challenge or not??

[Haffy fan]

Hi. I've owned my pony 8 months, he is 4yrs old. He had a 5 stage vetting prior to purchase, no issues, I purchase full insurance up to £5k. He Showed soreness in the stifle 2 weeks ago & was diagnosed with OCD, requiring an operation. The insurance company are saying it was pre-existing, so won't pay. They acknowledge that neither I nor the vet could have known he had it.

Has anyone successfully challenged this type of situation?

Any advice gratefully received. Thanks

 

[AmandaMT]

Do not go ahead with it I say. Been there and the insurance said yes but when in the operation refused meaning I lost £1,000+.

 

[Exploding Chestnuts]

Do not go ahead with it I say. Been there and the insurance said yes but when in the operation refused meaning I lost £1,000+.

What, you are telling us that just because the horse is not covered by insurance it must not get an operation it requires?

 

[Exploding Chestnuts]

Do not go ahead with it I say. Been there and the insurance said yes but when in the operation refused meaning I lost £1,000+.

What you mean is that you had to pay for the operation which the insurance company previously told you they would pay for, not that you lost £1000, I assume they denied having given you the go ahead?

 

[AmandaMT]

What you mean is that you had to pay for the operation which the insurance company previously told you they would pay for, not that you lost £1000, I assume they denied having given you the go ahead?

I mean they told me they would cover it all then while the operation was going ahead pulled out. It was only a warning that they could say yes and not mean it.

 

[Exploding Chestnuts]

Idly wondering if I know this company........ They were happy to take your money, but it is up to you to ask about the cover, I realise we are not experts, but they accepted the contract and now the fact that you insured in good faith. Really one could say almost any animal is pre-disposed to almost anything, they are not "well designed".

 

[applecart14]

They acknowledge that neither I nor the vet could have known he had it.

It is classed as a pre-existing condition. But at the same time you took precautions and had a five stage vetting so you did everything you could your end to ensure that your new purchase was risk free or as risk free as you could possibly know. I don't see how they can therefore not pay out.

I would seek legal representation or maybe consult the insurance ombudsman to get a clear definition of what is and what is not covered pre-existing or otherwise under english law.

I agree with Bonkers 2 when he/she says that any animal is predisposed to anything. Of course it is. If you bought an animal and it had cancer, or something similar where would you stand then I wonder?

Strikes me they will do anything to get out of paying up.

 

[Goldenstar]

I think I would challenge it too.

 

[Exploding Chestnuts]

I mean they told me they would cover it all then while the operation was going ahead pulled out. It was only a warning that they could say yes and not mean it.

They either agree to pay or they don't agree to pay, it sounds like you thought they had agreed to pay, but they had not. Where these things are concerned you need written confirmation. Our local vets do not agree to accept work via E&L for example, the owner is responsible for all the communications and all the payments. This is a decision they have made, they recommend certain companies well, [there are adverts in the vets premises] , for whatever reason, but the individual owner still has a choice.

 

[Haffy fan]

Hi, just to clarify, I informed them the vets diagnosis, sent X-rays etc, they said I'm not covered as pre-existing, my question is whether I should challenge them as to whether it is fair to use "pre existing" when there was no way of knowing this and when he was given a clear vetting? I am going ahead with operation & ombudsman assure me that they will have to pay up if they are found to be "unfair" even though they haven't given permission as there an animal in pain who can't wait 8 weeks for a response to my complaint.

 

[Haffy fan]

They have a Claus about pre existing conditions "whether or not they are evident to you or your vet" which is the bit i am thinking of challenging - kinda gets them out of anything really ....,

 

[applecart14]

They have a Claus about pre existing conditions "whether or not they are evident to you or your vet" which is the bit i am thinking of challenging - kinda gets them out of anything really ....,

Gosh that is so unfair. I have never heard of that before. So its a complete lottery. You spend all the money on a horse, spend all your money getting it vetted. And still it can develop something pre-existing and all your scrutiny, investigation, delving, exploration, analysis, examination, studying, probing and research makes no difference. Pants

 

[Haffy fan]

I'm hoping the ombudsman agrees with you applecart14 😬

 

[be positive]

I think as you had a 5 stage done and the horse has been sound for 8 months you should have a very strong case, it may be different if it was 8 weeks but it has taken a long time to show up, they are being unfair I hope you get the op paid for.

 

[soloequestrian]

I've had a case (involving a car, not a horse) that went through the ombudsman. They were really helpful, but it took about 2 years to process. I did finally get the money I was claiming though! I think insurance companies will do their very best to wear you down by prolonging the complaint process as long as possible - most people just give up at some point which gives the company more incentive to keep doing this! If the operation is happening anyway, you haven't anything to lose by pursuing your claim but be aware that it takes persistence! Do it though - if everyone did I think the insurance companies would start to clean up their act a bit!

 

[chestnut cob]

I'm another who thinks it is really unfair, they are just trying to get out of paying. You couldn't possibly have known the horse would develop OCD. As said above, maybe if you'd only had him for a few weeks they might have a case but you've had the horse for the best part of a year without any issue and had a clean 5 stage vetting.

I would absolutely challenge them. I think you have to start with the financial regulator then the ombudsman. I challenged Equestrian Direct (who changed their name or were bought around that time) as they tried to refuse a claim I made, but the moment they were threatened with the Ombudsman, they accepted it and paid up. OP it doesn't seem as though your insurer have any reason to refuse to pay.

Who are you with? I would absolutely be naming them, so that others can look out for that clause in their small print.

 

[Exploding Chestnuts]

Hi, just to clarify, I informed them the vets diagnosis, sent X-rays etc, they said I'm not covered as pre-existing, my question is whether I should challenge them as to whether it is fair to use "pre existing" when there was no way of knowing this and when he was given a clear vetting? I am going ahead with operation & ombudsman assure me that they will have to pay up if they are found to be "unfair" even though they haven't given permission as there an animal in pain who can't wait 8 weeks for a response to my complaint.

Good for you, stick to your guns and I think / hope you will be OK, the BHS legal helpline is great. And make sure you add on ALL costs you can.

 

[alsxx]

I agree, challenge them on this. But prepare yourself for a long and stressful battle.... I've been there and can honestly say it was the most awful 12 months of my life!!!! First of all though you will need to formally complain to the insurer. Only then, once you have had a response to the complaint will the ombudsman actually get involved and take a decision on the case (if they didn't respond to your complaint in your favour). I sent everything to the ombudsman at the same time as making my complaint (which was after 4 months of arguing with them), and damn well made sure the insurer knew that. They eventually found in my favour and the ombudsman reviewed everything and agreed with the eventual settlement.

There is a lot of info online regarding codes of conduct that insurers are supposed to follow, the more you dig, the more you can throw at them.

If you do go down this route they will likely refuse to insure you at your next renewal. I figured this might happen and arranged a new policy in advance with a different company as declaring you have been refused insurance can lead you to being refused insurance everywhere else! Charming really when all you are trying to do is be treated fairly!!!

 

[Honey08]

Best of luck OP. And I with Alsxx, change insurers before your policy is up next time if you 're going to re insure. I've scrapped my insurance this year, after deciding that most insurance companies are seriously weighting things unfairly in their favour nowadays, to the point that I don't see it worth having insurance anymore). I have BHS gold membership for third party and a credit card (until I save up more) for emergencies.

 

[nuttychestnut]

Challenge!
I successfully challenged the refusal to pay for treatment for my horse's OCD. It took 2 months to get the claim accepted & I had to submit competition results, videos, pictures & reports from my instructor to confirm that the horse was sound until I first noticed the lameness.
Just to add, not all OCD requires surgery or is a bleak outcome as shown via google!
Good luck!