DRN-6269614

The complaint Mr G complains that Wakam split a claim he made under his pet insurance policy over two cover periods and unfairly applied time limit deductions to the claims. What happened Mr G has a pet insurance policy underwritten by Wakam. He’s renewed the policy each year since inception in January 2021. When the policy renewed in January 2025 there was a change to the policy wording. Wakam reduced the time limit to make claims from 12 months to 6 months. This time started from the date the pet had treatment. The 2025/26 policy included the following: “3.2.1 Submitting your claims too late We don’t pay claims where invoices have been submitted more than 6 months after the date of treatment or service. You should submit your claims as soon as possible.” The 2024/25 policy included similar wording for the 12 months’ time limit. Claims for vet fees under the policy were subject to a £99 excess. On 12 December 2025, Mr G submitted a claim for the costs he’d incurred for his pet’s treatment between April 2024 and November 2025 – there were 20 invoices in total, amounting to a little over £370. Based on the dates of the invoices Wakam split the claim into two claims – one for policy year 2024/2025 and one for 2025/26. After deducting the earliest invoice (April 2024) on the basis that it had been paid under a previous claim, applying the respective 12 months and 6 months’ time limits, and subtracting the applicable excesses, Wakam reimbursed Mr G £17. In response to Mr G’s complaint about this, Wakam said the claim had been correctly split and assessed across two policy years and that the policy terms on late claims had also been correctly applied. Mr G referred his complaint to this service. He explained his pet has a condition for which regular treatment is necessary, and although he understood he’d left it late to claim, he said, “I feel the date I submitted it on isn’t relevant and hasn’t prejudiced the insurers in anyway.” Our Investigator upheld Mr G’s complaint. She said Wakam was entitled to assess the claim as two separate claims because the policy renews annually, and the treatment period spanned two policy years. However, she didn’t agree that Wakam had applied the late claims terms fairly. Whilst she acknowledged it is a policy term, she said Wakam hasn’t provided any evidence to demonstrate how it was disadvantaged by Mr G’s delay, and there’s nothing to suggest Wakam’s position would have been any different had the claims been submitted earlier. She said Wakam should pay Mr G the late claim deductions, plus interest, and pay him £100 for the distress and inconvenience caused by applying these deductions without demonstrating prejudice. Wakam rejected that assessment. It said, the application of a clearly communicated, reasonable, proportionate, and core, policy condition shouldn’t be contingent on the insurer demonstrating specific prejudice in each individual case. It explained:

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“… claim submission timeframes serve important operational and underwriting purposes. Late submission impacts the insurer’s ability to: • assess claims contemporaneously with treatment; • validate costs and query veterinary evidence while records are current; • accurately allocate claims to the correct policy period; and • maintain effective controls in relation to fraud and claims management.” Finally, it said there is no evidence that Mr G was prevented from submitting his claim within the applicable time limits or misled into believing the condition wouldn’t apply. As no agreement could be reached, the complaint has been passed to me to review afresh and decide. 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. Having done so, I’ve reached the same conclusion as the Investigator did and for similar reasons. I’ll explain why. The policy contained a time limit for the submission of claims and there is no disagreement about the fact that Mr G failed to adhere to that condition. He saved up all the small value claims over a period of 20 months and submitted them in one go, in December 2025. The invoice (and treatment) dates spanned two policy years, and I agree that it was fair for Wakam to assess the claims against the two policies in accordance with the dates covered by the invoices. It’s reasonable in my view that the invoices covering the period from April 2024 up to 23 January 2025 fell under policy year 2024/25, and those that came after that date and covered treatment up to 15 November 2025 were assessed against the 2025/26 policy wording. For completeness, I’m also satisfied that Wakam acted reasonably in declining to pay the invoice dated 2 April 2024 (£19.28) as it’s shown that this invoice had previously been submitted as part of an earlier claim, in May 2024. Turning to the time limit conditions (12 months for policy year 2024/25, and 6 months for policy year 2025/26) I don’t think Wakam has acted fairly. I accept that time limit conditions are not unreasonable and serve a legitimate operational purpose (for example, avoiding the evidential problems that might arise in assessing ‘stale’ claims). It’s therefore advisable for consumers to be aware of and adhere to such conditions. But our usual approach where a consumer is in breach of a condition relating to the procedure to be followed when making a claim, is to ask ourselves what the impact of that breach was. The reasonableness of an insurer’s response to such a breach will depend on the extent to which it has suffered any prejudice. In this case I can’t see that Wakam has been disadvantaged by Mr G’s delay. It has referred in general terms to how late submission might impact the assessment of a claim but has not shown that it actually had any impact in this case. If he’d made both claims within the time limit (12 months under the 2024/25 policy and within 6 months under the 2025/26 policy) the claims more likely than not would have been assessed and paid (subject to the applicable excesses) in the same way. Wakam has not shown that Mr G’s late submission impaired its opportunity to investigate the claim or prejudiced its ability to deal with the claim in any other way. Insurers are under an obligation to not unreasonably reject a claim (ICOBS 8.1.1) and Wakam has not shown that Mr G’s failure to comply with the condition in this instance

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exposed it to any greater risk than it would have been if he’d made the claims in time. I find Wakam has acted unfairly and unreasonably by seeking to reduce its liability on a ‘technicality’ when Mr G hasn’t, in fact, increased the risk of loss. My final decision For the reasons set out above, I uphold Mr G’s complaint about Wakam. So, my decision is that Wakam must pay Mr G: • the late claim deductions it made to his claims, plus simple interest using time- weighted average of the Bank of England base rate plus one percentage point. The interest should be paid from the date the claims were accepted (5 January 2026) to the date of settlement or to the deadline date I set out below, whichever is earlier. Wakam must make the payment within 28 calendar days from the date it is informed by us of Mr G’s acceptance of my final decision. If Wakam does not pay the compensation by this date, it should pay 8% simple interest per year on the late claim deductions it made to his claims, instead of Bank of England base rate plus one percentage point, for the period following the deadline to the date of settlement. • £100 for the distress and inconvenience caused to him by its unfair handling of the claims. Under the rules of the Financial Ombudsman Service, I’m required to ask Mr G to accept or reject my decision before 22 May 2026. Beth Wilcox Ombudsman

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