Red Sands Insurance Company (Europe) Ltd · DRN-6044119

The complaint Ms C complains that Red Sands Insurance Company (Europe) Ltd (Red Sands) unfairly declined a claim under her pet insurance policy. What happened The detailed background to this complaint is well known to both parties, so I’ll only summarise the key events here. Ms C holds a pet insurance policy, underwritten by Red Sands incepted from 21 October 2023 and renewed annually. In January 2025, Ms C made a claim for her dog’s dental treatment. But Red Sands declined the claim. It said Ms C’s claim was declined as the condition was deemed as pre-existing and non-compliance with the dental requirements under the policy terms. Ms C raised a complaint which she brought to our Service. Our Investigator considered the complaint and didn’t think Red Sands had acted fairly. So, she felt the claim should be settled in line with the remaining terms less the applicable excess with 8% simple interest awarded from date Ms C paid the vet to date of settlement. Red Sands didn’t agree and requested the case be reviewed by an Ombudsman. So, the complaint has been passed to me to make 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. The relevant industry rules and guidance say insurers must deal with claims promptly and fairly and support their customers in making claims. They should not unreasonably reject a claim. They should settle claims promptly once settlement terms are agreed. With insurance policies, the onus is on the policyholder to show a claim is covered under the policy terms. And if an insurer wishes to rely on an exclusion to decline a claim, as Red Sands have done here; the onus is on it to show the exclusion applies. So, my decision focuses on whether Red Sands has shown the exclusion more likely than not, applies. I’ve looked at the policy, and it covers the following for dental: “We’ll pay up to £1,000 for dental treatment, as long as your pet didn’t have any pre- existing dental conditions. A vet must have given your pet a dental exam within the last 12 months to confirm their teeth were healthy and any treatment must be carried

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out within 3 months. If you don’t follow these requirements, your claim will not be paid.” Red Sands declined Ms C’s claim as it said her dog’s dental condition was considered to be pre-existing as symptoms were noted before the policy started and also there was non- compliance with the requirements as set out above to cover the dental treatment. It relied on the following exclusion to decline the claim: “Pre-existing conditions aren’t covered in this policy. A condition, injury or illness is pre-existing if [dog’s name] has shown signs or symptoms before you joined [administrator’s name], or within the first 14 days of your initial policy start date. This also includes any other condition, injury or illness which is connected to that pre- existing condition as determined by a vet.” As Red Sands is seeking to rely on this exclusion, it has to establish that the treatment claimed for was related to a pre-existing condition. Red Sands has said since 2017 Ms C’s dog has had tartar. Recurrent notes over multiple years, confirm this was a chronic, progressive condition which would have led to the tooth extraction. I have carefully considered the vet’s notes relating to the treatment in the period before the claim, I’ve listed below the relevant comments from the notes: 15/12/2017 – “slight tartar on teeth no gingivitis” 15/06/2018 – “some tartar on upper canines” 12/11/2018 – “teeth – clean” 01/05/2019 – “teeth – clean” 07/09/2019 – “teeth – clean” 06/12/2019 – “teeth – clean” 30/01/2020 – “teeth - calculus 1/4 upper canines” 01/04/2020 – “teeth – clean” 23/06/2020 – “teeth – clean” 13/08/2020 – “teeth – clean” 22/04/2021 – “teeth - calculus 1/4" 29/09/2021 – “teeth mild tartar starting again” 01/02/2022 – “teeth OK as far can see - little tartar on upper canine teeth, owner brushes teeth daily (says some gingival bleeding on one side sometimes - to monitor, if persists then likely time for dental… dog won’t allow full dental exam” 12/11/2022 – teeth - ok 16/11/2022: – “moderate calculus” 14/01/2023 – “teeth lovely and clean – only small amt of calculus on canines that will need a dental s/p in the next 12months,..l” 20/02/2024 – “Dental ok” 28/02/2024 – “Canines hand-scaled” 11/06/2024 – “Dental ok” 03/12/2024 – “Moderate generalised dental tartar, furcation of 106 visible, able to pass probe through once under sedation… [Dog’s name] has generalised dental tartar with the roots of an upper right pre-molar exposed. It is advised for [dog’s name] to have all of her teeth cleaned and this tooth extracted under a general anaesthetic” 10/12/2024 – “Calculus build up throughout mouth but esp upper pre-molars and molars. Sum recession above 107/ Dark staining/colouration on 208 so possible fracture but tooth shape same as contralateral. Owner is keen to book dental in New Year” 03/01/2025 – “Surgically extracted teeth: 106 as probe passing through furcation… All remaining teeth scaled and polished”

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It’s clear from the vet’s notes, Ms C’s dog had dental check-ups through the course of regular trips to the vet, and I note the entries for tartar before the inception of the policy. But it is also noted that there are many entries showing the dog’s teeth were clean. But for me to say this was an indication of a pre-existing condition which led to the tooth extraction, I would have to be satisfied of two things – • that the condition being claimed for is the same as – or directly connected to – an illness or condition that was present before the policy started; and • at the point when she took out the policy, Ms C was aware there was something wrong with her pet Red Sands says in summary furcation refers to the area where the roots of a multi-rooted tooth divide. When furcation involvement occurs, the supporting structures of the tooth have been destroyed, typically due to chronic periodontal disease. Periodontal disease is a progressive condition caused by plaque and tartar build up (calculus), which harbours bacteria. Over time, plaque hardens into tartar, the bacteria in the plaque/tartar produce toxins that cause gingival inflammation. Over time the inflammation spreads deeper, damaging the supporting structures of the tooth. Furcation does not occur acutely; it’s the end result of a chronic disease process. It therefore says the condition necessitating extraction was linked to the chronic pre-existing dental disease. I note Red Sand has said furcation doesn’t occur acutely and is the end result of chronic disease process. If this is the case, then I would expect the vet notes to have picked up that Ms C’s dog was suffering from gingivitis and periodontal disease. But they don’t refer to this, and the entry prior to inception notes the dog s teeth are lovely and clean with just a small amount of calculus on canines. The canines were also not the tooth that was removed. Additionally, when the canines were scaled no mention was made of problems with the other teeth. And in June 2024 the teeth were noted as okay. Furcation can also be congenital so overall I’m not persuaded Red Sands has done enough here to link that the extraction was due to tartar build up. I’m satisfied the trip to the vets on 14 January 2023 was within the 12 months from inception of the policy and this met the requirements for a dental check within the last 12 months. However, I note it was recommended that the canines will need a dental s/p in the next 12 months. Ms C’s vet said on 20 February 2024 teeth okay and then when the dog was under sedation on 28 February 2024 for x-rays for a different illness/injury they hand-scaled the canines. So, this was treated albeit not in the 3 months as per the policy terms and conditions. But as I mentioned above the tooth that was extracted was not one of the canines in any event and I don’t find it unreasonable that Ms C was following her vets’ advice. Overall, I’m not persuaded Red Sands has shown the tartar led to the tooth extraction. And as far as Ms C was aware when she bought the policy, there was no issue with her dog’s teeth beyond some mild to moderate tartar, which she regularly cleaned. Therefore, she had no reason to believe this would lead to a claim. So, I’m not persuaded the exclusion for pre- existing conditions has been applied fairly in this case. It follows I don’t think Red Sands has acted fairly in declining this claim. Putting things right For the reasons I’ve explained above, I will be directing Red Sands to accept Ms C’s claim subject to the remaining policy terms and conditions. And if Ms C has already paid the vet’s fees, Red Sands should additionally pay 8% per annum simple interest on the settlement

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amount from when Ms C paid the vet’s invoice to when it makes settlement, on provision of substantiating evidence from Ms C. My final decision For the reasons I’ve explained above, I uphold this complaint and direct Red Sands Insurance Company (Europe) Limited to: • Accept Ms C’s claim for her dog’s dental treatment and pay interest on the amount as I have directed above. Under the rules of the Financial Ombudsman Service, I’m required to ask Ms C to accept or reject my decision before 20 February 2026. Angela Casey Ombudsman

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