Perhaps the most frequent reason pet insurance companies deny reimbursement for treatment is because they determine that the condition was pre-existing when you purchased the policy. Your pet's medical record is the primary way a pet insurance company determines what conditions are pre-existing.
As many of you know, I recommend asking the company that you choose to insure your pet to do a medical record review for a detailed look at your pet's past health history. This should be done after buying a policy and after the required waiting period for coverage to take effect, but within the first 30 days. Essentially, this means that the company will review your pet's medical record and inform you (in writing) if there are any previous health problems that are pre-existing, and therefore, not covered by the policy. You can usually get a full refund of your premium if you haven't filed a claim yet within the first 30 days.
Unfortunately, not all companies are willing to do this and I think it goes to the issue of transparency. The last thing a policyholder wants to do is pay premiums for perhaps years only to discover that something isn't covered. This is one of the questions on the Step 3 worksheet in the Pet Insurance Toolkit that helps you narrow down your choices of companies to insure your pet. You need to know if a company is willing to do a medical record review before you purchase.
When you initiate your policy, some companies will ask several questions about previous medical conditions. If a medical record review isn't done when you initiate a policy, the company will most likely request medical records when you file your first claim - especially if it is for an illness. You might be surprised at what all is in your pet's medical record.
The following things will come to light when the company reviews your pet's medical record:
- Did you forget to mention something when answering questions during the application process? For example, you may have forgotten that time you took your pet to a different veterinarian or to an emergency clinic when your vet was closed.
- Perhaps you just casually mentioned something to your veterinarian during a visit that he or she noted in your pet's medical record. This could be a signal to a pet insurance company of a potential pre-existing condition whether you or your vet considered it a big deal or not.
- If you changed vets, the hospital likely requested your pet's medical record from your previous vet.
- All your pet's x-ray and lab test results will be included. The pet insurance company may determine an abnormal lab test is significant whether your veterinarian considered it to be so or not. Sometimes lab results slightly out of the normal range will be not be considered significant if your vet doesn't think it relates to the current problem and/or can be explained in combination with other test results.
So, be sure to include all medical records when requesting a medical record review - your regular vet, vaccination clinic, emergency/specialty hospital, that time you went to another vet when your vet was closed or you wanted a second opinion, etc.
When you have a medical record review done, you may already have an idea of one or more problems that they will discover and determine is pre-existing. Even so, this may be acceptable to you when you consider all the things that will be covered. There's another advantage to having a medical record review before you file your first claim. Any questions about whether a condition is covered or not can usually be decided quickly resulting in quicker reimbursement.
There are often “grey areas” when deciding if a condition is pre-existing. For example, is the current episode of diarrhea related to an episode that occurred before you purchased insurance? Unless the cause of the diarrhea in either case is specifically known, it may be impossible to say for sure. I believe that’s when common sense should prevail.
Pet insurance policies usually have a “reach back period” (my terminology) of 6 months, 1 year, 18 months, 2 years, etc. before you purchased the policy that they use to determine if a condition is pre-existing or not when deciding whether to cover or deny a claim. Obviously, a shorter reach back period is preferable. You can find these clauses in a sample policy, usually where the definition of pre-existing conditions appears (always read a sample policy before purchasing insurance). For example:
"A condition will no longer be considered pre-existing if your pet's condition has been cured and free from treatment and symptoms for a period of 180 days."
- "Illnesses or Injuries for which signs or evidence of their potential manifestation existed within the 18 months prior to the Policy Enrollment Date.
Let’s say your pet is insured and has diarrhea that your veterinarian diagnoses and treats. If the pet had an episode of diarrhea before purchasing insurance within the specified reach back period, they may deny the claim and say it was a pre-existing condition. Obviously, this gives the company a lot of wiggle room to justify denying a claim vs. siding with the pet owner and paying the claim. This is especially applicable if it is one of those “grey areas” where you simply cannot say definitively whether the two episodes are related. My opinion as a veterinarian is - if it’s truly a grey area situation, how about giving the benefit of the doubt to the pet owner and the pet?
A Word To Veterinarians
How you word problems in the medical record may help eliminate some of these "grey" areas. I realize that we've never had to be cognizant of this before, but just consider what I'm about to say in light of your clients who have pet insurance and especially those who will purchase pet insurance in the future.
We all know that pets rarely present to us with diagnoses; rather they present with problems. Differentiate between problems and diagnoses. Don't define a problem at a higher resolution than you know for sure and can defend. Always link a problem with a specific diagnosis when you can. For example, is it undefined diarrhea (no known cause) or is it due to giardiasis? Try not to put guesses in the medical record, but only what you know for sure.
A Word To Pet Owners
Clients can help their veterinarian out in this regard also. When your vet recommends tests to diagnose a problem, doing the test will help the veterinarian rule out certain possible diagnoses and help bring clarity to the problem. Hopefully a definitive diagnosis can be found and specific treatment provided.
Here are a couple of steps you can take to minimize problems with pre-existing conditions:
- Carefully screen companies before purchase (reviews) to find companies that seem to side with the policyholder and find a reason to pay vs. deny a claim - especially in those grey area situations. Be sure to look at both favorable and unfavorable reviews. Pay attention to comments that follow a review, especially if it is from a representative of the insurance company. Did their explanation as to why the claim was denied seem reasonable in light of the terms of the policy? When possible, it helps to get "the other side of the story" when looking at negative reviews.
- Ask for a medical record review after purchasing a policy.
Of course, purchasing pet insurance early on - before your pet develops medical conditions will go a long way toward eliminating a lot of these concerns.