DRN-6272772

The complaint Mrs B is unhappy with what Allianz Insurance Plc did after she made claims on her pet insurance policy. What happened Mrs B took out pet insurance with Allianz on 10 March 2025 covering her dog (B). She claimed on her policy for treatment B had received for lameness which was observed by her dog walker on 21 March. Allianz said the policy didn’t cover costs relating to an illness where symptoms were observed within the first 14 days of the policy year. It thought that was the case here and declined the claim. Mrs B’s vet then said information it provided about the cause of the lameness was wrong. This wasn’t due to obesity (as the claim form said) but resulted from acute elbow injury as a result of impact trauma. Allianz referred the matter to both an inhouse and independent vet. They thought the lameness was caused by illness. The X rays showed sclerosis (increased bone density) which was a sign of elbow dysplasia and could result from abnormal weight distribution. And the treatment prescribed for B was commonly used to treat degenerative joint problems. As no specific injury episode had been observed they thought an illness was the most likely caused of the lameness. Allianz maintained its position on the decline of the claim. But it said in its final response to Mrs B’s complaint it would review matters if further evidence was provided including a written rationale from Mrs B’s vet as to why the lameness wasn’t caused by a degenerative condition. Our investigator reviewed the evidence including the veterinary records which included a note from 27 March 2025 which said “looks like an acute injury”. She thought it most likely that was the case meaning the claim should be covered by Mrs B’s policy. She said Allianz should settle the claim and pay Mrs B interest on any amounts she’d already paid to her vet. And it should also pay her £200 to recognise the distress and inconvenience it caused. Mrs B agreed with her outcome and confirmed she had paid the vet for the treatment costs. She said there had been a miscommunication at her vet’s which led to incorrect information about the cause of the lameness being provided on the paperwork (which had subsequently been clarified). Allianz was basing its diagnosis of an illness on the opinion of two vets who hadn’t seen B. Prior to the lameness developing B had been walking normally and no issues had been observed on her previous visits to the vet. Since being treated she’d made a full recovery which wouldn’t have been the case if elbow dysplasia was the cause of her lameness. Allianz didn’t agree with our investigator. It said: • When the claim was submitted Mrs B’s vet said the lameness resulted from obesity which they confirmed in a subsequent email. That matched the symptoms and was in line with the sclerosis that was subsequently found (and would have been present at the point the lameness occurred).

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• There wasn’t evidence of B suffering a traumatic injury and there was no reference to that in the initial notes after B was seen by the vet. That vet only suggested to it that was the case after the claim had been declined. • Both its inhouse and an independent vet agreed illness was the likely cause of B’s lameness. They’d also advised the treatment options adopted in this case wouldn’t be appropriate for the treatment of an injury (unless there was evidence of massive trauma which wasn’t the case here). It was normally used for treating joint disease. • It thought it likely B hadn’t suffered an injury but her lameness was caused by obesity induced elbow dysplasia. So the claim had been correctly declined as an illness showing symptoms within the first 14 days of the policy starting wasn’t covered. I issued a provisional decision on the complaint last month. In summary I said: The relevant rules and industry guidelines say Allianz has a responsibility to handle claims promptly and fairly. It shouldn’t reject a claim unreasonably. Mrs B’s policy covers the cost of veterinary treatment B receives during the policy year to treat illness or injury. But it doesn’t cover an injury or symptoms of an illness in the ‘waiting period’ even if the treatment takes place after that period has passed. The policy explains “If your pet has an injury in the first 48 hours of their first policy year we’ll never cover any costs relating to that injury. This is whether treatment is needed in the first 48 hours or later on. If your pet has symptoms of an illness in the first 14 days of their first policy year we’ll never cover any costs relating to that illness. This is whether treatment is needed within the first 14 days or later on”. Illness is defined as “any sickness, disease, defect, abnormality and/or change from a healthy state. This includes any defect or abnormality which your pet was born with or which was passed on by his/her parents”. Injury means “accidental physical damage or trauma caused immediately by an external source. Not any physical damage or trauma that happens over a period of time”. And symptoms means “any change from a healthy state, bodily function or behaviour”. B didn’t have an injury in the first 48 hours of the policy year. But her lameness was noticed on 21 March 2025 which was within the first 14 days of the policy year. So, and as I think all parties agree, the key question in terms of policy cover is whether the treatment B then received was for an illness or an injury. I’ve considered all of the evidence in relation to that. Mrs B’s vet has been clear in correspondence with Allianz (after the claim was initially declined) that he believed the lameness was caused by an “isolated incident”. And although B had been put on a weight loss diet that was to help the injury heal and wasn’t the cause of it. He subsequently advised the incident was a fall in a field probably related to uneven ground. But I do think it was reasonable of Allianz to have concerns about this information the vet provided about the claim. Both of the claim forms have separate sections for the vet to complete. In each case the cause of the treatment is recorded as “lameness due to obesity”. I think it’s significant Allianz then contacted the vet for clarification. In response they said “yes we are happy that the diagnosis of this lameness is linked/caused by [B’s] obesity”. The vet has said there was confusion about the claim caused by the involvement of a new member of staff. But it’s not clear to me why that would have led to inaccurate information being provided in an email responding to a specific question asked by Allianz. Given that, I think it was reasonable Allianz placed less weight on the information provided by the treating vet than might otherwise have been the case.

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And I think there’s also reasonably persuasive evidence of an alternative cause for the lameness. Both of the vets Allianz referred the matter to concluded B was showing signs of sclerosis (which is an indicator of underlying elbow dysplasia; a major cause of lameness). Allianz’s in house vet went on to comment that the treatment B was prescribed was “more commonly used in degenerative/arthritic joint management, this treatment is not consistent with a 1-month history of lameness due to a simple injury”. I appreciate neither of those vets saw B at the time of the incident. But they did review the clinical notes including the X ray taken at the time. And in any event Mrs B’s vet accepted in correspondence with Allianz that there was evidence of “mild sclerosis”. Of course the fact B was showing signs of sclerosis doesn’t in itself mean that was related to her lameness. Something else could have caused that such as an injury. The difficulty here is that there’s no persuasive evidence such an injury occurred. The only specific reference to this is a comment on the X ray by Mrs B’s vet. That says “looks like an acute injury”. But there’s no further supporting rationale in relation to that and it isn’t supported by either Allianz’s inhouse vet or the independent vet. Allianz’s inhouse vet said “in the x-ray images the radius has an odd opacity mid-way which the significance isn’t clear, the elbow joint does have some changes which is more consistent with degenerative joint disease not injury”. The other evidence doesn’t show B’s lameness was caused by an injury as defined in the policy either. There’s no reference to that in the notes from when B was first taken to the vet. And Mrs B wasn’t present when the lameness developed as B was with her dog walker. I understand she said B was having a run in a field when the problem started. But she doesn’t appear to have seen B fall or otherwise suffer an external trauma. So while B may well have been walking normally prior to that there doesn’t appear to be clear evidence of her suffering an injury here. I recognise B may not have then had further problems following treatment. And I understand elbow dysplasia can’t be cured. But effective treatment (including weight loss) can limit or eliminate its symptoms. So I don’t think the fact B’s symptoms haven’t recurred to date means elbow dysplasia wasn’t the cause of her lameness. Nevertheless, I do accept the evidence is conflicting in this case. I recognise Mrs B’s vet has been clear that in his professional opinion an acute injury is more likely the cause of the lameness. I’ve also taken into account that he had the benefit of examining B following the incident. But in my view the inconsistencies in the information he provided, which contradict what was reported at the time, do detract from the weight that can be given to his opinion. In any case he and the other vets all agree that B was suffering from sclerosis. And given the time taken for that to develop I think that will have been the case at the point the lameness developed. In the absence of clear evidence of an alternative cause for that lameness (an injury) I think it was fair of Allianz to conclude the cause of that was most likely associated with the sclerosis affecting B. That would meet the definition of illness the policy contains. As that showed symptoms within 14 days of the policy starting (and was something Mrs B was aware of at that point) I think it was fair of it to decline cover for the claims she made. I appreciate Mrs B has paid her vet for those treatment costs and this means she won’t be reimbursed for those. I’m very sorry to bring her what I do appreciate will be extremely disappointing news. Of course if Mrs B is able to provide the further information Allianz referenced in its final response to her complaint I’d expect it to review matters. Responses to my provisional decision Allianz didn’t respond. Mrs B did make some further comments. She said B’s dog walker reported she had developed a sudden limp immediately after running and playing with other

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dogs and had no history of lameness prior to that. She also provided a video showing B moving normally. So she thought the most likely cause of B’s issues was an injury and she had now made a full recovery following treatment. She didn’t think sufficient weight had been given to the opinion of the treating vet who reviewed B and monitored her recovery. And he’d confirmed the treatment B received was the result of an injury and explained why the condition wasn’t linked to obesity. She queried why his opinion had been given less weight than vets who hadn’t seen B. And she said only minor changes were noticed on the X rays which weren’t considered clinically significant. Veterinary records didn’t diagnose sclerosis or identify it as the cause of the lameness. And she thought we should review call recordings to check whether Allianz had led opinions towards the conclusion it wanted to obtain. So I need to reach a final 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. I recognise Mrs B feels we should obtain call recordings (for example between Allianz and her vet). But I’m satisfied I already have the information I need to reach a fair outcome on this complaint. In particular the opinion of Mrs B’s vet is clearly set out in the information he provided. He made clear he believed B’s lameness related to a fall in a field. The issue is what weight should be given to that evidence. And I explained in my provisional decision why I thought it was reasonable of Allianz to have some concerns about what he said. In particular his explanation for the cause of the lameness didn’t match with the claim forms previously completed. Both of those said the treatment was required because of “lameness due to obesity”. The vet confirmed that in a follow up email. A reason for that discrepancy has been provided but I’m not persuaded that does fully explain it. I think it was reasonable Allianz therefore placed less weight on the opinion of the treating vet. And I think it was appropriate for it to consider the alternative cause for the incident put forward by the other vets it referred the matter to. It was their opinion (which Mrs B’s vet also accepted) that B was showing signs of sclerosis which is an indicator of underlying elbow dysplasia. That doesn’t in itself mean it was the cause of B’s lameness but it remains my view there isn’t persuasive evidence of an alternative cause for that. I appreciate B may well have been moving normally when she went for her walk (and that’s supported by the video Mrs B has supplied). But the dog walker didn’t see her fall and there’s no reference to an injury having occurred in the veterinary notes. I appreciate (and I’m pleased to hear) B hasn’t shown further symptoms following treatment. But I understand effective treatment for elbow dysplasia (including weight loss) can limit or eliminate its symptoms. So the fact the problem hasn’t recurred doesn’t mean elbow dysplasia wasn’t the underlying cause. It remains my view that, in the absence of clear evidence of an alternative cause for the lameness (an injury), it was fair of Allianz to conclude the cause was more likely associated with the sclerosis affecting B. And as that occurred within 14 days of the policy starting it was entitled to turn down the claim on that basis. My final decision I’ve decided not to uphold this complaint. Under the rules of the Financial Ombudsman Service, I’m required to ask Mrs B to accept or reject my decision before 26 May 2026.

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James Park Ombudsman

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