Jarred had two French bulldogs, Malcolm and Fred. Because they were important to him, Jarred decided to take out pet insurance when they were approximately two years old, in June 2016.
In April 2015, Malcolm was taken to the vet because his dog-day-care noticed that he was coughing and dry heaving. After some medication and monitoring, Malcolm was found to have an infection and was sent home.
In October 2015, Malcolm again required a visit to the vet. Jarred noticed he had been coughing for about a week and the coughing usually culminated in dry retching.
Because of Malcolm’s coughing episodes prior to policy inception, the insurer decided to provide Jarred with cover for Malcolm, but subject to an exclusion for any illness relating to, or resulting from a cough or respiratory system disorders.
In February 2017, while being walked, Malcolm collapsed open-mouthed and breathing heavily. The vet recommended surgery to clear Malcolm’s airways. This involved surgery on ‘stenotic nares,’ ‘an elongated soft palate’ and ‘everted lateral ventricles.’ Because it was a matter of urgency, Jarred booked the surgery thinking that the insurer would reimburse him at a later date.
Jarred thought that, given he had seen two different vets who said that the previous coughing episodes had no connection with the surgery required, cover was a foregone conclusion.
When the insurer declined Jarred’s claim, he complained to FSCL.
The insurer said Jarred’s policy did not cover the treatment cost of a condition specifically excluded on his insurance certificate. The insurer believed the surgery was for an illness or injury related to Malcolm’s ‘respiratory system disorder.’
The insurer said Malcolm had respiratory problems in April and October 2015 before cover commenced. Although there was the ability to review special exclusions after 12 months, the surgery happened within 12 months of policy inception.
The insurer outlined that the respiratory system includes the nose, mouth, pharynx, larynx, trachea and lungs. On the basis that the nose (stenotic nares), mouth (elongated soft palate) and larynx (everted lateral ventricles) are part of the respiratory system, and that disorders of the respiratory system were specifically excluded under Malcolm’s policy, the insurer believed it was entitled to decline the claim.
Jarred said that although Malcolm had had a mild cough when he was attending doggy-day-care, he had never been diagnosed with ‘kennel cough.’ Jarred stressed that it was less of a cough and more a ‘couple of snorts.’ He believed the additional exclusion endorsed on the policy was a response to Malcolm’s previous episodes of coughing. Because the surgery Malcolm had received was not specifically related to coughing, Jarred reasoned that the exclusion could not be relied on.
We said that although the insurer applied an exclusion to the policy in response to the coughing episodes, the policy also excluded injury, illness or conditions relating to respiratory system disorders. While Jarred thought the exclusion was unfairly broad, the wording was clear that treatment for respiratory systems was not covered (including but not limited to coughing.)
It did not matter why the exclusion was placed on Malcolm’s policy. The wording was clear, and Malcolm’s treatment clearly fell within the exclusion.
Jarred had also been given a chance by the insurer, when he bought the policy, to read and review the terms and, if they were not agreeable, decline to take cover.
Key insight for consumers
Although exclusions may be placed on policies after specific events, they will not necessarily only exclude illnesses or events which relate to that specific event. It is important to read and understand the full scope of any policy exclusion.