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Unrelated illness and injury but same clinical sign

In June 2016, Ligaya bought pet insurance for her puppy, Dusty.

In July 2016, Dusty was running on a wooden floor in Ligaya’s house when he slipped and fell over onto his hip. Ligaya thought that Dusty was limping a little and that he may be in pain. She took him to the vet where Dusty was given some painkillers. The following day, Dusty was back to his usual self.

In September 2016, Ligaya noticed that Dusty’s back legs seemed stiff. By the end of that day, Dusty was just standing in one place and whimpering in pain.  Ligaya took Dusty to the vet where he was given painkillers. However, the vet could not determine what was wrong with Dusty.

Dusty was referred to a specialist vet who diagnosed Dusty with immune mediated arthritis, an autoimmune disease. Dusty was given a course of steroids and recovered.

Ligaya then submitted a claim to her pet insurance for the cost of the treatment Dusty had received.

The insurance company declined Ligaya’s claim.


The insurance company’s position

The pet insurance policy included a 21 day stand-down period. This meant that the insurance company would not accept any claims arising from treatment of an illness or disease which the pet first showed clinical signs of within 21 days of the policy’s start date.

Dusty’s vet visit in July 2016 for his sore hip was within 21 days of the policy start date so this visit was not covered under the policy. However, the insurance company said that Dusty’s vet treatment in September 2016 was also not covered under the policy.

The insurance company said that because Dusty displayed the same ‘clinical signs’ for both vet visits, being a sore/stiff leg, it was entitled to decline the claim.


Ligaya’s position

Ligaya believed the insurance company was wrong. Dusty’s vet said that Dusty’s vet visits in July and September were unrelated.


Our view

We contacted the insurance company to say that we were having difficulty accepting its reasons for declining the claim. The medical notes for Dusty showed that the vet found that Dusty’s July injury was unrelated to his September illness. We placed weight on the vet’s expert evidence. We considered that the 21 day stand down period exclusion clause did not apply in the circumstances of Dusty’s claim.

We told the insurance company that we considered it was relevant that Dusty’s injury and illness were unrelated and that excluding claims where unrelated illness/injuries share a clinical sign would lead to absurdity.



Following our further communication with the insurance company, the insurance company accepted Ligaya’s claim. Ligaya was very happy with this outcome.