When Samantha insured her kitten, Comet, the insurer excluded from cover “any illness or condition, clinical sign or diagnosis caused by, relating to or resulting from (GA0) gastro-intestinal/digestive system disorders.”
About six months later Samantha took Comet to the vet, concerned that Comet was listless, had not been eating and may be constipated. The vet’s notes confirmed Comet had a high temperature, a tender abdomen, was dehydrated and an x-ray revealed “bony material in faecal bulk”. Comet responded well to antibiotics prescribed by the vet and quickly improved. The vet gave her opinion that Comet was suffering from a fever of unknown origin, and that constipation was a symptom and not the cause of Comet’s illness.
Samantha submitted an insurance claim for vet costs of $1,200.
The insurer’s view
The insurer declined Samantha’s claim because Comet showed clinical signs of constipation and the policy excluded clinical signs relating to gastro-intestinal/digestive system disorders.
Samantha did not accept the insurer’s view saying constipation was the result, not the cause, of Comet’s illness. Comet’s constipation was caused by Comet’s high temperature, fever, dehydration and failure to eat. In Samantha’s view Comet’s fever was covered by the policy, and should extend to covering all the consequences of Comet’s illness.
Samantha complained to FSCL.
We explained the insurer’s obligation to pay Comet’s vet fees were found in the insurance policy. In our opinion the policy wording was very wide, capturing Comet’s constipation, allowing the insurer to decline the claim. Although the vet’s opinion supported Samantha’s view that constipation was not the primary cause, it did acknowledge that constipation was a factor.
We advised our preliminary view that the insurer was entitled to decline the claim. Although disappointed with the outcome, Samantha accepted our view.
Key insights for consumers
The starting point of almost every complaint about insurance is the policy wording. In this case the widely drafted policy excluded cover for any condition relating to a gastro-intestinal disorder meaning that regardless of the actual cause, if a gastro-intestinal disorder was involved the claim would be declined.