Admiral Insurance (Gibraltar) Limited · DRN-6032489

The complaint Mr W complains that Admiral Insurance (Gibraltar) Limited declined a claim on his pet insurance policy. What happened Mr W took out a pet insurance policy for his dog in October 2024. The policy is underwritten by Admiral. He made a claim on the policy for treatment relating to ear and eye infections but Admiral declined the claim. Admiral says its decision is based on veterinary advice and: • The claim was for otitis and bacteria alone doesn’t cause this. It’s a secondary factor and there is an underlying cause, most likely allergies. • Mr W’s dog had known allergies, so that was the most likely explanation here. • The policy started in October 2024 and allergies were present before then, so this is a pre-existing condition. Mr W says his dog only had three isolated infections over the previous five years before the policy started, with no mention of allergies, and there’s no connection between the conditions claimed for and those previous infections. Our investigator noted that Admiral had acknowledged some poor service and paid compensation for that, which she said was fair. But she did not think it was fair to decline the claim and recommended that Admiral settle the claim. Admiral disagrees and has requested an ombudsman’s decision. What I’ve decided – and why I’ve considered all the available evidence and arguments to decide what’s fair and reasonable in the circumstances of this complaint. The relevant industry rules and guidance say insurers must deal with claims promptly and fairly, support a policyholder to make a claim, and not unreasonably reject a claim. The starting point for considering whether the claim was dealt with fairly is the policy terms. The policy covers treatment costs but, there is an exclusion for “The recurrence or continuation of illness or disease from which your pet(s) previously suffered arising prior to or within 14 days of the start of this insurance.” This is not unusual and pet insurance generally wouldn’t cover something that was present before the insurance started or within the first 14 days of the policy. I’ve considered Admiral’s comments carefully but I don’t think it was fair in this case to decline the claim as a pre-existing condition, for the following reasons:

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• Mr W has a valid claim for treatment costs, unless there’s an exclusion that applies. The onus is on Admiral to show it’s fair to apply the exclusion in the circumstances of his case. • The policy excludes claims where the treatment is for something that is a “recurrence or continuation of illness or disease” that was present before the policy started. • So to decline the claim, Admiral needs to show the conditions claimed for were present before the policy started (or, at the very least, had the same cause). • Their vet says otitis externa on its own wouldn’t cause the problems – this is a secondary infection, there will always be an underlying cause, and the most likely cause is an allergy. • Otitis externa can be caused by many different things. There may often be an underlying allergy, but it could be caused by something else, such as an autoimmune disease, a foreign body or some other cause. • If Mr W’s dog had been suffering with allergies I’d expect to see that recorded in the records, with advice or treatment for it, but that’s not the case here. • With regard to the eye infection, Admiral has also referred to the fact Mr W’s dog had been diagnosed with entropion before the policy started, but it hasn’t provided persuasive evidence showing a connection between the infection claimed for and the entropion. • While it’s possible the problems were due to an underlying allergy, I don’t consider the evidence of that persuasive and it’s equally possible there was another cause. • Even if there is a connection between the conditions claimed for and the previous issues, it wouldn’t generally be fair to refuse a claim if the consumer couldn’t reasonably have known there was a problem. As far as Mr W was aware, there had been three isolated events some years apart, each of which had been treated and resolved quickly. He wasn’t told his dog had ongoing allergies and wouldn’t have been aware when he bought the policy that there was any ongoing issue. So Admiral should not apply the exclusion, and should settle the claim in the line with the remaining policy terms. There was some poor service in relation to the claim handling but Admiral acknowledged that and paid some compensation, which I agree was fair. My final decision I uphold the complaint and direct Admiral Insurance (Gibraltar) Limited to • settle the claim in line with the remaining policy terms and conditions, including any policy limits and excess due; and • if Mr W has already paid the vet’s fees, pay interest from the date he paid them to the date of settlement at 8% a year simple. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr W to accept or reject my decision before 20 April 2026. Peter Whiteley Ombudsman

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