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Why do Pet Health Insurance Claims get rejected?


Something we see not infrequently in small animal practice, is the frustrating and sad occurrence when insurance claims are rejected. Understandably, this can cause additional upset and worry for owners, who are already preoccupied with the health and well-being of their pet undergoing treatment. In this article we take a look at some of the common reasons why pet insurance claims might be rejected. We hope to provide some basic guidance in terms of issues that might cause a headache for an unwitting owner needing to make a claim.

The scenarios

We all know what it’s like these days. The internet, whilst a wonderful resource can, quite often, provide us with a mind-boggling provision of too much information. No doubt in searching for a pet health insurance policy (PHIP), many a diligent owner might easily spend hours researching and comparing different policies. With a few clicks of a mouse, a purchase can rapidly be made; insurance companies often luring new customers in with offers of free cover for a month or such like.

But once the policy documents land with a thud on the doormat, or arrive with a ping into our email inbox, who really takes time to read the small print of their policy?

As a starting point, I would always recommend that once purchased, you READ your policy documents, paying particular attention to the detailed terms and conditions. Ensure that what you have purchased, really fits your needs and that the policy is as you were expecting.

The first 14 days

As the norm, any PHIP is unlikely to cover any illness seen/contracted within the first 14 days after the policy inception. Some leniencies may be given by certain policies for any (purely) accidental injuries incurred during this time (rather than illnesses themselves) although this will vary policy by policy. 

Pre-existing conditions (PEC’s)

For as long as I can remember, many pet insurance companies have been similar, in that they will not provide cover for any pre-existing health conditions (PECs) that have affected your pet in their previous medical history. That is to say, that if, when your pet is middle aged you decide to change PHIs, any diagnosis/condition made prior to the change of policy, will not be covered.

Some insurance companies go so far as to exclude any SYMPTOM that was seen historically in the past. Say for example, your current 4-year-old Labrador had (what was diagnosed at the time as), a simple gastroenteritis aged 1-year-old, which manifested as vomiting or diarrhoea. If you change insurance policies, the new policy may potentially exclude ANY cover for gastrointestinal related symptoms in the future. This can be a significant disadvantage.

Gastrointestinal disease, skin conditions (including ears), lameness and lumps/bumps are too frequently fall foul of this, when an owner changes policies.

Interestingly, a recent development with one insurance provider has been that they will now take on such animals with PEC’s. If no related disease is seen within the subsequent 2 years, the exclusion is lifted thereafter.

Common other exclusions

Routine treatments which are typically considered as “preventative,” such as vaccinations, flea and worming treatments and neutering, are rarely ever covered by PHIP’s. Some exceptions may exist where an animal is neutered specifically as part of recommended treatment on veterinary advice.(For example an elderly, entire male dog with testicular cancer who undergoes castration as part of the treatment of the disease).

Any costs associated with breeding (or whelping) such as a caesarean section, are also unlikely to be covered.

The cover for any dental treatment will vary policy by policy; but typically a “scale and polish” procedure may not draw cover. Dental work performed following an accident/trauma (a fractured tooth which requires extractions for example), more likely might be covered.

Dogs imported from abroad might also potentially be problematic, if for example, they were infected with an infectious disease (not endemically or typically seen in the UK), such as Babesia, Leishmania etc). 

A PHIP may also not cover for disease or illness (or death which arises from a disease), which could have been avoided by the use of preventative medication. (Parvovirus infection in an unvaccinated dog for example). Conversely, it may also be a criterion of your policy that your pet is kept up to date with their vaccinations, so as not to invalidate the cover.

Also likely are exclusions on any PHIP relating to the costs of cremation or body disposal at the end of your pet’s life. Home visits and transportation costs may also not be covered or may only be covered if they were deemed explicitly necessary (in the considered opinion of the veterinarian).

Food?

Sadly, even if a prescription veterinary diet is recommended and prescribed by your vet, it is unlikely to be covered by your PHIP. (Such as a renal diet for a cat with chronic kidney disease; or a hydrolysed food for a dog with inflammatory bowel disease). A few exceptions might exist, for example if a diet is recommended for the dissolution of urinary bladder crystals or stones or, if a liquid diet is used (most likely via a feeding tube) in a hospitalised patient requiring intensive nutritional support. However, in the main, food, even if prescription, will likely not be a valid claim on most pet insurance policies.

Level of fees

Certain insurance companies will also set predetermined levels of costs that they are prepared to pay, for any one particular diagnostic test or procedure. This, according to the veterinary fees charged, may mean that a portion of your costs are not covered.

Pre-authorisation

If your pet requires a (non-emergency) investigation, referral or surgery, one option with your PHIP might be to enquire whether they would consider pre-authorising such costs. To obtain such authorisation (and thereby reassurance that the policy will respond to the claim), might however take a few days. And so would, therefore, be unlikely to be feasible in an emergency setting.

Read the small print!

So, my industry insider’s top tips for pet insurance are:

  • get the best policy you can consistently afford on an ongoing basis, from the start of your pet’s life…
  • … and do not change it thereafter! 
  • choose a lifetime policy with as much cover as you can afford. Ideally a few thousand pounds, per condition, per year, for life
  • and, read the small print of any policy you purchase to ensure you are fully aware of all the T&C’s.
  • If contemplating changing insurance policies, consider asking your vet for a copy of your pet’s clinical records. This is so that you may identify where a new company might have reason to believe that certain conditions are pre-existing.

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