Old dog, new claim

In September 2017, Aaron’s dog, Lincoln, fell off Aaron’s bed and injured his elbow. Aaron took Lincoln to the local vet, who performed several scans and diagnosed Lincoln with a ligament strain and severe lameness in the injured leg. The vet recommended several treatments, and Lincoln was soon back on his feet.

Aaron made a claim to his insurer for his $4,568 in veterinary bills. When his claim was declined, Aaron complained to FSCL.

 

Dispute

The insurer said Lincoln’s policy specifically excluded any claims related to the arthritis in Lincoln’s right front foot. Lincoln’s vets said that the injury was exacerbated by an ‘arthritic crisis’. The insurer took the view that the arthritis in Lincoln’s elbow was likely related to the arthritis in his foot, so cover for the injury was excluded.

Aaron did not accept that the exclusion covered Lincoln’s injury. Aaron reasoned that the injury was to Lincoln’s elbow, not his foot, so the exclusion should not apply.

 

Review

Although we accepted that the arthritis in Lincoln’s foot had not caused his injury, we found it was possible the arthritis and the injury were related.

After reviewing the medical evidence provided by Lincoln’s vets, we said it was possible that the injury and the arthritis were related. Lincoln’s injury was exacerbated by the arthritis in his elbow, and the arthritis in Lincoln’s elbow may have been a symptom of the same arthritis which appeared in his foot.

However, we found that the medical evidence of Lincoln’s vets was not enough to conclusively link the arthritis in Lincoln’s foot to the arthritis in his elbow. Although Lincoln’s vets described the foot and elbow arthritis in similar terms, they had not considered or directly addressed the possibility that the elbow and foot arthritis were related.

 

Outcome

Due to the lack of evidence linking the arthritis in Lincoln’s foot and elbow, we found the most reasonable outcome would be for Aaron and the insurer to equally share the costs of Lincoln’s treatment. We formally recommended the insurer pay Aaron a sum of $2,284. The insurer and Aaron settled on this basis.

 

Key insights for the complainant

Exclusions in insurance policies are often worded broadly. If your policy contains an exclusion for an existing medical condition, it will likely exclude cover any related injuries or illnesses. This is worth considering when assessing whether your insurance cover justifies your premiums.

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