Pet Insurance Disputes

Pet insurance in Australia has grown rapidly — over 7% of dogs and cats are now insured — but claim denials are equally common. The most frequent dispute is over "pre-existing conditions," where the insurer argues that a condition existed before the policy started. Expert veterinary evidence can challenge this determination and is often the difference between a denied claim and a successful outcome at AFCA (Australian Financial Complaints Authority).

Pre-Existing Condition Disputes

Insurers define "pre-existing" broadly — often including conditions that showed clinical signs before the policy start date, even if the owner was unaware. Expert veterinary evidence can challenge this by demonstrating:

• The condition is genuinely new: Just because a dog had a limp in 2023 does not mean the cruciate ligament rupture in 2025 is the same condition — they may have entirely different causes
• Clinical signs were non-specific: A single episode of vomiting noted in veterinary records does not constitute a "pre-existing gastrointestinal condition" — it could have been caused by dozens of transient factors
• Bilateral conditions are not automatically pre-existing: If a dog tore its left cruciate ligament before the policy and later tears the right, the insurer may argue the right was pre-existing — expert evidence on bilateral cruciate disease can rebut this
• Breed predisposition is not pre-existence: The fact that a breed is prone to a condition does not mean the condition existed at policy inception

Treatment Necessity Disputes

Insurers sometimes deny claims arguing the treatment was not "medically necessary" or was "experimental." Our experts provide evidence on:

• Whether the recommended surgery or treatment was appropriate given the diagnosis and prognosis
• Whether the chosen treatment was consistent with current veterinary practice guidelines
• Whether a less expensive treatment would have been equally effective (or whether the insurer is pushing a substandard alternative)
• Whether ongoing treatment (physiotherapy, long-term medication) is genuinely necessary for recovery

AFCA Complaints

If internal dispute resolution with the insurer fails, pet owners can escalate to the Australian Financial Complaints Authority (AFCA). AFCA is a free service that makes binding decisions on financial complaints. Expert veterinary evidence significantly strengthens AFCA complaints by providing an independent clinical opinion that the AFCA case manager can rely on when the insurer's in-house vet has made the denial decision.

We understand AFCA's evidence requirements and format our reports accordingly — focused on the specific policy wording, the clinical timeline, and whether the insurer's denial was consistent with veterinary science.

For Insurers — Independent Claim Assessment

We also work with pet insurers who need independent veterinary assessment of claims — particularly complex or high-value claims where the insurer wants an expert opinion before making a coverage decision. Our assessment is independent: if the claim is legitimate, we say so; if it isn't, we explain why in terms that will withstand AFCA scrutiny.