Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear below.First, Ms [redacted] says, "it is not really a waiting period, but an exclusion due to a pre-existing condition" Well if I have to wait months, to me, that is a waiting period.Second, she can get into the semantics of what is or isn't dermatological, but the vet did submit documentation to Embrace that clearly stated the ear infection had nothing to do with any other type of skin condition, and should not be considered pre-existing For the record, the dog had an allergic reaction causing irritation on the bottom of her paws and an infected incision from the spaying surgery The ear infection occurred as a result of water getting in the ear from a bath at a grooming facility.Third, she references email to me on 8/ The only email I have that resembles anything like what she is referring to was actually on 8/about an orthopedic report card I admittedly did not send that to my vet to complete, but that is not related to this issue.Fourth and most importantly, they are standing on the grounds of "Our policy states no dermatological conditions can be covered if any dermatological conditions were noted before the start of the policy." This is not the case The policy started on 7/ The condition that Embrace is considering pre-existing occurred on 7/but was only brought to their attention on 9/when I erroneously submitted a claim for the 7/vet visit because I had forgotten that was prior to the policy being in effect So Embrace in fact did not note any dermatological condition prior to the start of the policy Per their policy exclusions, "clinical signs of any dermatological condition prior to the end of the waiting period" - the waiting period would have been 7/19-8/ That should eliminate anything prior to 7/ They bound the policy on 7/with receipt of medical history from the vet So again, I stand by my complaint that either the claims should be paid or my premiums refunded, less the one $claim that was paid [To assist us in bringing this matter to a close, we would like to know your view on the matter.] Regards, [redacted]
Dear Revdex.com, I have reviewed Mr [redacted] ’s response and would like to discuss his rebuttal statements below This case all boils down to the fact that dermatological condition occurred before the start of the policyMr [redacted] himself acknowledges thisThe policy is clear that if any dermatological condition happens before the start of the policy, no matter the cause, (water in the ear, contact dermatitis from a shampoo, etc.) no dermatological conditions can be covered until all dermatological conditions are clear for a full monthsRelationship between the conditions does not have to exist to fit this clause of the terms and conditions so the veterinarian's statement of non-relation in this case is immaterial Part I- Definitions Dermatological Condition means an Illness related to your Pet’s skin and is deemed to include ear infections and skin lumps but not conjunctivitis or parasitic infestations Part I- Exclusions iIf your pet showed clinical signs of any dermatological condition prior to the end of the waiting period, your pet must be free of any dermatological conditions for twelve (12) consecutive months before any dermatological conditions may be covered again His reasoning about why we found out about the pre-existing dermatological condition, his erroneous claim, is a non-starter We routinely request all medical history before we process the first illness claim so we can learn of any possible pre-existing conditionsWhether the claim had been submitted or not, the prior dermatological conditions were recorded in the medical history and were listed as pre-existing conditions upon our review Additionally, Mr [redacted] states, “Per their policy exclusions, "clinical signs of any dermatological condition prior to the end of the waiting period" - the waiting period would have been 7/19-8/ That should eliminate anything prior to 7/19.” The date of 7/19/is prior to the end of the waiting periodThe policy does not say only things in the waiting period are pre-existingIt says any illness or abnormality before (prior) the end of the waiting period will be deemed pre-existing conditionsWe routinely review the last months of medical history and make note of pre-existing conditions, not just what occurred in the first days of the policyThis practice is standard for every pet insurance company, though some review or months of medical history Again, I assert [redacted] ’s claim was processed appropriately according to the policy terms and conditions, and I therefore cannot offer Mr [redacted] a full refund as per his request If Mr [redacted] would like to cancel his policy at this time we can offer him a prorated refund for the unused portion of the current policy month as is our policy for any policy holder I am sorry if the exclusions and policy terms and conditions were not clear at the start of the policy and Mr [redacted] should feel free to call us with any questions, concerns, or if he would like to cancel his policy I hope this addresses the complaint in its entirety and feel free to contact me directly with any issues Best regards, [redacted] ***, RVT Claims Manager, Embrace Pet Insurance v
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear below I've personally concluded that her foot-licking was a reaction to chemical treatments on the grass at the apartments where I had lived at the timeSince moving, I have noticed no licking of the feet at allDespite his excessive treatment for allergic conditions, my dog's sire licks his feet excessively due to a developing benign tumor on his footGiven the genetics, it's possible she may have been gradually developing one unseen as wellThere are many possible explanations for her conditions at the time of that visit, and allergies were discussed as a possible concern in the future during the visit, but it was in no way conclusively determined at that timeThe cause of her yeast infection in April, was inconclusive and may have been due to inadequate drying after bathingAfter some changes in her grooming, her symptoms went away and were not seen againWhat she experienced in August was dramatically different from what she had experienced in April, with widespread hair loss and lesions across her neck and faceTHIS was determined to be an allergic reactionThere was no conclusive determination prior to the policy that she was experiencing any allergic reactionsI DID know prior to the policy that she could potentially develop these in the very near future based on her sire's recent diagnoses and treatment (he had hair loss and lesions covering his entire body.) It is because of the genetic connection creating a concern of potential need that I sought coverageThere was no need prior to coverageBy rejecting my claims, considering my financial status, the rate at which her sire's condition progressed, and the fact that no other insurance would cover her claims now that she's definitively experienced allergic symptoms, Embrace is dooming her to a miserable existence for the remainder of her lifespanPunishing the consumer for being hyper-vigilant of his pet's health prior to coverage is a VERY poor legacy for a pet insurer Regards, [redacted]
Dear Revdex.com, I am happy to address Mr [redacted] ’s concerns and explain the details on why the claims and appeal were not coveredIt is certainly not in order to be fraudulent or “find any justification to deny”, as Mr [redacted] has stated The issue in this case is not one of an additional, hidden waiting period, but one of a pre-existing conditionOur policy states no dermatological conditions can be covered if any dermatological conditions were noted before the start of the policy until dermatological conditions have been clear for monthsThe following excerpts are from the policy terms and conditions: Part I- Definitions Dermatological Condition means an Illness related to your Pet’s skin and is deemed to include ear infections and skin lumps but not conjunctivitis or parasitic infestations Part I- Exclusions iIf your pet showed clinical signs of any dermatological condition prior to the end of the waiting period, your pet must be free of any dermatological conditions for twelve (12) consecutive months before any dermatological conditions may be covered again [redacted] ’s owner has already stipulated that a dermatological condition did occur before the start of the policy, meaning we are unable to cover any dermatological conditions until [redacted] has been free of other dermatological conditions for months I will address Mr [redacted] ‘s concerns in order “First, an ear infection is not dermatological.” The inside of the ears are covered in a layer of dermis and most vets will agree they are often affected like other exposed parts of the skinWe include ear infections in our definition of dermatological specifically to clear up any confusion on how we treat the ears “Second, I was given no notification of such a waiting period.” As I have already explained above it is not really a waiting period, but an exclusion due to a pre-existing conditionUpon signup for this policy, on 8/5/Mr [redacted] was offered a medical history review once medical records were receivedHe did not respond with a request for a reviewHe was also informed in the same email and another email on 8/6/the medical history is collected but remains on file until we receive [redacted] ’s first claimWe would not have any way of knowing what pre-existing conditions exist until the history is reviewed for the first claim unless a history review was requested by the pet parentIn this case, no review was requested “Third, the vet specifically documented the complete lack of any relation of the conditions the claims were submited for to the pre-policy dermatitis.” With the policy terms and conditions written the way they are, the pre-existing dermatological condition does not need to be ‘related’ to the claimed dermatological condition, they just have to both be dermatological in nature as defined by the policy to apply to this exclusion The dermatological exclusion for [redacted] is temporary and can expire as long as he is clear of dermatological conditions for months Due to the above factors we are not able to cover the claims and comply with Mr [redacted] ’s request to “pay the claims in the amount of $as submitted.” In regard to his other request, to “refund all premiums paid,” we can only do something of this nature within the first days of the start of the policyMr [redacted] ’s policy has been in place since 7/19/This is also outlined in our policy terms and conditions: Part VII- Other terms and conditions Cancellation refundUpon cancellation, you may be entitled to a premium refundIf you provide us written notice of cancellation within thirty (30) days of the effective date and you have made no claim, we will refund the premium you paid us and the policy will be cancelled If Mr [redacted] would like to cancel his policy at this time we can offer him a prorated refund for the unused portion of the current policy month I am sorry if the exclusions and policy terms and conditions were not clear at the start of the policy and Mr [redacted] should feel free to call us with any questions, concerns, or if he would like to cancel his policy at this time I hope this addresses the complaint in its entirety and feel free to contact me directly with any issues Best regards, [redacted] ***, RVT Claims Manager, Embrace Pet Insurance
Dear Ms.***
Thank you for advising us of *** ***’s complaint; ID ***. I do understand the pet parent’s frustration,
but I’m afraid we are unable to provide coverage for his claims or to provide
him a full refund as he requestedThe policy terms and
conditions clearly
define his pet as having a pre-existing condition that has not remained
resolved for consecutive months and Mr*** has received coverage for his
pet for other coverable conditions
Mr***’s pet, ***, was noted to have undiagnosed
diarrhea prior to the purchase of the policy making the clinical sign of
diarrhea and any related conditions a pre-existing condition. The policy considers this a temporary
exclusion and will provide coverage for the condition as long as *** is free
of the clinical signs and any related conditions for consecutive
months. Unfortunately, *** had
recurrent bouts of diarrhea and has been unable to meet the month
requirement.
***’s policy began on 1/6/and had a fourteen (14) day waiting
period for all illnesses and accidents, which ended on 1/19/14. The policy defines a pre-existing condition
as: an illness or injury that first occurred or showed Clinical Signs prior to
the end of the Waiting Period for your Pet and any related conditions
***’s medical history documented diarrhea on 7/17/and
on 8/1/noted “has always had loose stools”.
Diagnostics to determine the cause of the diarrhea and loose stool had
not been performed, so the policy considers this to be an undiagnosed clinical
sign. *** was noted to have
diarrhea/loose stools again on 2/16/14, 2/17/14, 2/21/and 3/3/14. The diagnosis presented on the claim form for
the 3/3/claim noted the pet to have giardia, which is an intestinal parasite
that causes diarrhea. The claims for
giardia cannot be covered because *** had undiagnosed diarrhea prior to the
start of the policy making diarrhea and any related conditions, such as
giardia, pre-existing and not coverable unless resolved for consecutive
months
The policy cannot provide a full refund of premium paid
because Mr*** did have coverage for his pet, ***, for any condition deemed
coverable by the policy terms and conditions.
The policy reimbursed the full amount agreed upon for his wellness
coverage, and provided coverage with reimbursement for two illness claims that
were submitted
I would also like to address Mr***’s reference to
reducing the waiting period of the policy.
In addition to the fourteen (14) day waiting period, the policy has a six
(6) month waiting period for orthopedic conditions. There is no option to waive the fourteen (14)
day waiting period but pet parents due have the option to reduce the six (6)
month orthopedic waiting periodThe orthopedic waiting period can be reduced from
six (6) months down to fourteen (14) days or the date of the orthopedic
examination if this occurs after the fourteen (14) day waiting period The policy requires an orthopedic examination
to occur after the start date of the policy.
A specific form must be completed by the examining veterinarian and sent
to Embrace. To date, Embrace has not
received the orthopedic examination form to reduce this waiting period. Mr*** submitted a claim for an orthopedic
condition during this six (6) month orthopedic waiting period. This claim was not coverable as the condition
was found prior to the end of the orthopedic waiting period making the
condition pre-existing
I’m sorry that we cannot provide coverage for Mr***’s
claims or provide him with a full refund.
The policy does provide a pro-rated refund amount, which Mr***
received when he cancelled, but cannot provide a full refund because coverage
was in effect. The policy would and did
provide coverage for conditions not noted to be present prior to the start of
the policy or within either of the policy’s waiting periodsI would have hoped
Mr*** could see the benefit of the policy and the many conditions that would
have coverage; however, I understand his frustration with not having some of
his claims covered and his decision to cancel
Please feel free to contact me if you have any questions or need additional information
Best regards,
*** ***
senior claims adjuster
(800) 511-
EmbracePetInsurance.com | Facebook
| Twitter
Hello again
Revdex.com and Ms***,
I am happy
to keep explaining this situation until Ms*** is more satisfied
We are not
permitted to assume an onset date of an illnesses and, as such, we did not
assume anything in this caseAs I have noted in my prior responses the medical
notes from 1/15/stated and I quote “Presented for lameness of RF (right
front) legDuration > month.” Also, the veterinarian’s appeal letter
noted and I quote, “During my exam I asked the owner the duration of condition,
the owner stated it was approximately month”Therefore, no assumptions were
madeWe took the onset of this lameness directly from the two written sources
we were provided withBoth sources agree the onset of this lameness was before
the completion of the policy orthopedic waiting period
I understand
Ms*** is not happy with the result of her claim and appeal, however, I
believe I have addressed all of the points she has brought up in this and my
previous responses
Please let
me know if there is any other information you need from Embrace
*** ***
Claims
Manager
Embrace Pet
Insurance
I am happy to address the situation concerning C***’s
lameness claims for Revdex.com review
Ms***’s policy started on 7/1/14, and included a
month orthopedic waiting period that expired on 1/1/This waiting period can
be reduced to days with completion of an orthopedic exam by a
veterinarian after
the purchase of the policyThis is exam is optional and we do not have records
of this exam on file for C*** so his waiting period stood to expire on 1/1/
We are only able to make decisions for coverage on what
information we are provided with from the veterinarianIn this case, the
medical records for the first visit for lameness on 1/15/state “Presented
for lameness of RF (right front) legDuration > month.” This puts the
onset of the lameness into the orthopedic waiting period since that waiting
period did not end until 1/1/The policy terms and conditions state any ab
signs noted by the pet parent or
veterinarian within the defined waiting periods will create exclusions of
coverage in the policyThe following is an excerpt from the policy terms and
conditions:
Pre-existing Condition(s) means:
aa Chronic Condition observed by you (the policy holder) or your Veterinary
Provider prior to the end of the Waiting Period for your Pet(s) and any related
conditions; or ban Illness or Injury that first occurred or showed Clinical
Signs prior to the end of the Waiting Period for your Pet and any related
conditions. Undiagnosed conditions with
the same Clinical Signs as those in aor babove are also considered
pre-existing
Ms*** did appeal the claims, however, the appeal
information from DrB*** confirmed the onset of the clinical signs of the
lameness were approximately one month and the appeal was not successfulThe
letter from DrB*** did also state the condition is not pre-existing since
he had not previously diagnosed it, but as our terms and conditions state, that
is not needed for a condition to be pre-existingA pre-existing condition as
defined by the policy is any condition showing signs during a waiting period or
before the start of the policy
Additionally, for the appeal our senior claims adjuster
reviewed all of the notes from ** StateWe did not have those notes prior to the
appealThose notes also have the duration of the lameness as one month,
putting the onset in the orthopedic waiting period
Unfortunately, due to the above evidence and the policy
restrictions, I am unable to acquiesce to the stated desired settlement to
cover the lameness condition for C***
*** ***
Claims
Manager
Embrace Pet
Insurance
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below
[To assist us in bringing this matter to a close, we would like to know your view on the matter.]
Regards,
*** ***
I am sorry for Ms. [redacted]’s frustration. The main points
of her frustration seems to be a delay in processing her claim and the
inconsistency in what information she was given about the timeline for claims
processing.
I will first address the timeline itself of this claim....
The
claim documentation was received into our fax system on 10/15/14, was processed
and setup as a claim on 10/20/14 and was processed on 10/29/14. We are experiencing some delays at this
time due to a systems upgrade that has put some kinks into our efficiency,
however, this claim was processed within the 8-10 business day window Ms.
[redacted] was given on her first contact for this claim.
The second issue is one of consistency with the time line
estimates. I agree the outline of what Ms. [redacted] was told through the
contact center was inconsistent. We are experiencing some delays of our normal processing
times, and had not updated our ‘claim received’ email to reflect this. We also
had not updated our estimate for the customer contact group to give to our policy
holders when they called to inquire on their claims. We have addressed these
issues in the following ways: the email now accurately reflects our current
processing time (20-25 business days) while we endeavor to catchup with our
current backlog of claims, and we have also instituted more training for our
customer contact center group in regards to estimates for claims.
[redacted], RVT
Claims Manager
Embrace Pet Insurance
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.
I've personally concluded that her foot-licking was a reaction to chemical treatments on the grass at the apartments where I had lived at the time. Since moving, I have noticed no licking of the feet at all. Despite his excessive treatment for allergic conditions, my dog's sire licks his feet excessively due to a developing benign tumor on his foot. Given the genetics, it's possible she may have been gradually developing one unseen as well. There are many possible explanations for her conditions at the time of that visit, and allergies were discussed as a possible concern in the future during the visit, but it was in no way conclusively determined at that time. The cause of her yeast infection in April, 2014 was inconclusive and may have been due to inadequate drying after bathing. After some changes in her grooming, her symptoms went away and were not seen again. What she experienced in August was dramatically different from what she had experienced in April, with widespread hair loss and lesions across her neck and face. THIS was determined to be an allergic reaction. There was no conclusive determination prior to the policy that she was experiencing any allergic reactions. I DID know prior to the policy that she could potentially develop these in the very near future based on her sire's recent diagnoses and treatment (he had hair loss and lesions covering his entire body.) It is because of the genetic connection creating a concern of potential need that I sought coverage. There was no need prior to coverage. By rejecting my claims, considering my financial status, the rate at which her sire's condition progressed, and the fact that no other insurance would cover her claims now that she's definitively experienced allergic symptoms, Embrace is dooming her to a miserable existence for the remainder of her lifespan. Punishing the consumer for being hyper-vigilant of his pet's health prior to coverage is a VERY poor legacy for a pet insurer.
Regards,
[redacted]
Dear Revdex.com,
I am happy to address Mr. [redacted]’s concerns and explain
the details on why the claims and appeal were not covered. It is certainly not
in order to be fraudulent or “find any justification to deny”, as Mr. [redacted]
has stated.
The issue in this case is not one of an...
additional, hidden
waiting period, but one of a pre-existing condition. Our policy states no
dermatological conditions can be covered if any dermatological conditions were
noted before the start of the policy until dermatological conditions have been
clear for 12 months. The following excerpts are from the policy terms and
conditions:
Part I- Definitions
15.
Dermatological Condition means
an Illness related to your Pet’s skin and is deemed to include
ear infections and skin lumps but not conjunctivitis or parasitic infestations.
Part I-
Exclusions
1. I. If
your pet showed clinical signs of any dermatological condition prior to the end
of the waiting period, your pet must be free of any dermatological conditions
for twelve (12) consecutive months before any dermatological conditions may be
covered again.
[redacted]’s owner has already stipulated that a
dermatological condition did occur before the start of the policy, meaning we
are unable to cover any dermatological conditions until [redacted] has been free
of other dermatological conditions for 12 months.
I will address Mr. [redacted]‘s concerns in order.
“First, an ear infection is not dermatological.” The inside
of the ears are covered in a layer of dermis and most vets will agree they are
often affected like other exposed parts of the skin. We include ear infections
in our definition of dermatological specifically to clear up any confusion on
how we treat the ears.
“Second, I was given no notification of such a waiting
period.” As I have already explained
above it is not really a waiting period, but an exclusion due to a pre-existing
condition. Upon signup for this policy, on 8/5/14 Mr. [redacted] was offered a
medical history review once medical records were received. He did not respond
with a request for a review. He was also informed in the same email and
another email on 8/6/14 the medical history is collected but remains on file
until we receive [redacted]’s first claim. We would not have any way of knowing
what pre-existing conditions exist until the history is reviewed for the first claim
unless a history review was requested by the pet parent. In this case, no
review was requested.
“Third, the vet specifically documented the complete lack
of any relation of the conditions the claims were submited for to the
pre-policy dermatitis.” With the policy terms and conditions written the way
they are, the pre-existing dermatological condition does not need to be ‘related’
to the claimed dermatological condition, they just have to both be dermatological
in nature as defined by the policy to apply to this exclusion.
The dermatological exclusion for [redacted] is temporary and
can expire as long as he is clear of dermatological conditions for 12 months.
Due to the above factors we are not able to cover the
claims and comply with Mr. [redacted]’s request to “pay the claims in the amount
of $341.13 as submitted.”
In regard to his other request, to “refund all premiums
paid,” we can only do something of this nature within the first 30 days of the start
of the policy. Mr. [redacted]’s policy has been in place since 7/19/14. This is
also outlined in our policy terms and conditions:
Part
VII- Other terms and conditions
3. Cancellation refund. Upon
cancellation, you may be entitled to a premium refund. If you provide us
written notice of cancellation within thirty (30) days of the effective date
and you have made no claim, we will refund the premium you paid us and the
policy will be cancelled.
If Mr. [redacted] would like to cancel his policy at this
time we can offer him a prorated refund for the unused portion of the current
policy month.
I am sorry if the exclusions and policy terms and conditions
were not clear at the start of the policy and Mr. [redacted] should feel free to
call us with any questions, concerns, or if he would like to cancel his policy at this time.
I hope this addresses the complaint in its entirety and
feel free to contact me directly with any issues.
Best regards,
[redacted], RVT
Claims Manager,
Embrace Pet Insurance
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.First, Ms. [redacted] says, "it is not really a waiting period, but an
exclusion due to a pre-existing condition". Well if I have to wait 12 months, to me, that is a waiting period.Second, she can get into the semantics of what is or isn't dermatological, but the vet did submit documentation to Embrace that clearly stated the ear infection had nothing to do with any other type of skin condition, and should not be considered pre-existing. For the record, the dog had an allergic reaction causing irritation on the bottom of her paws and an infected incision from the spaying surgery. The ear infection occurred as a result of water getting in the ear from a bath at a grooming facility.Third, she references email to me on 8/5. The only email I have that resembles anything like what she is referring to was actually on 8/18 about an orthopedic report card. I admittedly did not send that to my vet to complete, but that is not related to this issue.Fourth and most importantly, they are standing on the grounds of "Our policy states no dermatological conditions
can be covered if any dermatological conditions were noted before the start of
the policy." This is not the case. The policy started on 7/19. The condition that Embrace is considering pre-existing occurred on 7/14 but was only brought to their attention on 9/22 when I erroneously submitted a claim for the 7/14 vet visit because I had forgotten that was prior to the policy being in effect. So Embrace in fact did not note any dermatological condition prior to the start of the policy. Per their policy exclusions, "clinical signs of any dermatological condition
prior to the end of the waiting period" - the waiting period would have been 7/19-8/2. That should eliminate anything prior to 7/19. They bound the policy on 7/19 with receipt of medical history from the vet. So again, I stand by my complaint that either the claims should be paid or my premiums refunded, less the one $38 claim that was paid.
[To assist us in bringing this matter to a close, we would like to know your view on the matter.]
Regards,
[redacted]
Dear Revdex.com,
I have reviewed Mr [redacted]’s response and
would like to discuss his rebuttal statements below.
This case all boils down to the fact that
dermatological condition occurred before the start of the policy. Mr. [redacted]
himself acknowledges this. The policy is clear that if any dermatological condition happens before the start of the
policy, no matter the cause, (water in the ear, contact dermatitis from a
shampoo, etc.) no dermatological
conditions can be covered until all
dermatological conditions are clear for a full 12 months. Relationship between
the conditions does not have to exist to fit this clause of the terms and
conditions so the veterinarian's statement of non-relation in this case is immaterial.
Part I- Definitions
15.
Dermatological Condition means
an Illness related to your Pet’s skin and is deemed to include
ear infections and skin lumps but not conjunctivitis or parasitic infestations.
Part
I- Exclusions
1. I. If
your pet showed clinical signs of any dermatological condition prior to
the end of the waiting period, your pet must be free of any
dermatological conditions for twelve (12) consecutive months before any
dermatological conditions may be covered again.
His reasoning about why we found out about the
pre-existing dermatological condition, his erroneous claim, is a non-starter.
We routinely request all medical history before we process the first illness
claim so we can learn of any possible pre-existing conditions. Whether the
claim had been submitted or not, the prior dermatological conditions were
recorded in the medical history and were listed as pre-existing conditions upon
our review.
Additionally, Mr. [redacted] states, “Per their
policy exclusions, "clinical signs of any dermatological condition prior
to the end of the waiting period" - the waiting period would have been
7/19-8/2. That should eliminate anything
prior to 7/19.” The date of 7/19/14 is
prior to the end of the waiting period. The policy does not say only things in the waiting period are
pre-existing. It says any illness or abnormality before (prior) the end of the waiting
period will be deemed pre-existing conditions. We routinely review the last 12
months of medical history and make note of pre-existing conditions, not just
what occurred in the first 14 days of the policy. This practice is standard for
every pet insurance company, though some review 18 or 24 months of medical
history.
Again, I assert [redacted]’s claim was processed appropriately
according to the policy terms and conditions, and I therefore cannot offer Mr.
[redacted] a full refund as per his request.
If Mr. [redacted] would like to cancel his policy
at this time we can offer him a prorated refund for the unused portion of the
current policy month as is our policy for any policy holder.
I am sorry if the exclusions and policy terms
and conditions were not clear at the start of the policy and Mr. [redacted]
should feel free to call us with any questions, concerns, or if he would like
to cancel his policy.
I hope this addresses the complaint in its
entirety and feel free to contact me directly with any issues.
Best regards,
[redacted], RVT
Claims Manager,
Embrace Pet Insurance
v
I am happy to address Mr. [redacted]’s concerns and explain
the details on why his pet [redacted]’s claims were not covered.
To begin, we do cover genetic conditions (and all other conditions)
as long as there are no signs of them before the start of the policy. If there
is a clinical sign of an...
issue before the start of the policy, it is considered
a pre-existing condition. This is true of all pet insurance companies.
[redacted] had a visit on 4/24/14 where her vet described her to
have pruritus (itching), a severe ear infection, and yeast dermatitis in skin
folds and on her chin. On 5/28/14 she was noted to be licking her feet which
can be a sign of itchy feet and allergies. The policy was purchased on 7/14/14,
and the policy 14 day waiting period was complete on 7/29/14. On 8/8/14 [redacted] was
seen for an ear infection, skin fold dermatitis and was ultimately diagnosed
with atopy.
Our policy terms and conditions concerning this issue are as
follows:
Part I- Definitions
15. Dermatological Condition means an Illness related to
your Pet’s skin and is deemed to include ear infections and skin lumps but not
conjunctivitis or parasitic infestations.
Part I- Exclusions
1. I. If
your pet showed clinical signs of any dermatological condition prior to the end
of the waiting period, your pet must be free of any dermatological conditions
for twelve (12) consecutive months before any dermatological conditions may be
covered again.
The exclusion section of the terms and conditions above specifies
any dermatological condition noted before the start of the policy creates an
exclusion for any dermatological condition unless the pet can be free of
dermatological conditions for a full 12 months. This did not happen in [redacted]’s
case. She had dermatological issues in April, again in May, and was diagnosed
with allergies/ atopy in August.
We did receive a letter from Mr. [redacted]’s veterinarian on
2/19/15 and it is in the process of being setup, however, I do not expect the
appeal will be successful in overturning [redacted]’s claims in light of the clinical
signs of dermatological issues seen before the start of the policy.
As for the desired settlement, if Mr. [redacted] would like to
cancel his policy we can offer him a prorated refund for the unused portion of
this month’s premiums as we would for any pet parent wishing to cancel his
policy. I am sorry I cannot offer more, but we have upheld the policy terms and
conditions as stated.
Mr. [redacted] should feel free to call us with any questions,
concerns, or if he would like to cancel his policy.
I hope this addresses the complaint in its entirety and feel
free to contact me directly with any issues.
Best regards,
[redacted], RVT
Claims Manager,
Embrace Pet Insurance
Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.This is an assumption made by EMBRACE. I never told my VET that he was lame for over a month. He had just started limping for about a week before I brought him in to the point of no relief with rest. I would never let my pet go for a month liming without seeking medical attention. He has other issues as a pup, one with his tail and lump on back foot that made him limp from time to time but it WAS NOT because of his shoulder. They are trying to find an excuse not to pay this claim. My Vet even sent a letter that this was not pre-existing in his medical opinion. If C[redacted] had any prior history of limping it would have been noted in his medical history during prior Vet appointments and Wellness visits. They need to pay this claim as they are denying this on an assumption.
He is my dog and I know this was NOT pre-existing!Regards,[redacted]
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear below.First, Ms [redacted] says, "it is not really a waiting period, but an exclusion due to a pre-existing condition" Well if I have to wait months, to me, that is a waiting period.Second, she can get into the semantics of what is or isn't dermatological, but the vet did submit documentation to Embrace that clearly stated the ear infection had nothing to do with any other type of skin condition, and should not be considered pre-existing For the record, the dog had an allergic reaction causing irritation on the bottom of her paws and an infected incision from the spaying surgery The ear infection occurred as a result of water getting in the ear from a bath at a grooming facility.Third, she references email to me on 8/ The only email I have that resembles anything like what she is referring to was actually on 8/about an orthopedic report card I admittedly did not send that to my vet to complete, but that is not related to this issue.Fourth and most importantly, they are standing on the grounds of "Our policy states no dermatological conditions can be covered if any dermatological conditions were noted before the start of the policy." This is not the case The policy started on 7/ The condition that Embrace is considering pre-existing occurred on 7/but was only brought to their attention on 9/when I erroneously submitted a claim for the 7/vet visit because I had forgotten that was prior to the policy being in effect So Embrace in fact did not note any dermatological condition prior to the start of the policy Per their policy exclusions, "clinical signs of any dermatological condition prior to the end of the waiting period" - the waiting period would have been 7/19-8/ That should eliminate anything prior to 7/ They bound the policy on 7/with receipt of medical history from the vet So again, I stand by my complaint that either the claims should be paid or my premiums refunded, less the one $claim that was paid [To assist us in bringing this matter to a close, we would like to know your view on the matter.] Regards, [redacted]
Dear Revdex.com, I have reviewed Mr [redacted] ’s response and would like to discuss his rebuttal statements below This case all boils down to the fact that dermatological condition occurred before the start of the policyMr [redacted] himself acknowledges thisThe policy is clear that if any dermatological condition happens before the start of the policy, no matter the cause, (water in the ear, contact dermatitis from a shampoo, etc.) no dermatological conditions can be covered until all dermatological conditions are clear for a full monthsRelationship between the conditions does not have to exist to fit this clause of the terms and conditions so the veterinarian's statement of non-relation in this case is immaterial Part I- Definitions Dermatological Condition means an Illness related to your Pet’s skin and is deemed to include ear infections and skin lumps but not conjunctivitis or parasitic infestations Part I- Exclusions iIf your pet showed clinical signs of any dermatological condition prior to the end of the waiting period, your pet must be free of any dermatological conditions for twelve (12) consecutive months before any dermatological conditions may be covered again His reasoning about why we found out about the pre-existing dermatological condition, his erroneous claim, is a non-starter We routinely request all medical history before we process the first illness claim so we can learn of any possible pre-existing conditionsWhether the claim had been submitted or not, the prior dermatological conditions were recorded in the medical history and were listed as pre-existing conditions upon our review Additionally, Mr [redacted] states, “Per their policy exclusions, "clinical signs of any dermatological condition prior to the end of the waiting period" - the waiting period would have been 7/19-8/ That should eliminate anything prior to 7/19.” The date of 7/19/is prior to the end of the waiting periodThe policy does not say only things in the waiting period are pre-existingIt says any illness or abnormality before (prior) the end of the waiting period will be deemed pre-existing conditionsWe routinely review the last months of medical history and make note of pre-existing conditions, not just what occurred in the first days of the policyThis practice is standard for every pet insurance company, though some review or months of medical history Again, I assert [redacted] ’s claim was processed appropriately according to the policy terms and conditions, and I therefore cannot offer Mr [redacted] a full refund as per his request If Mr [redacted] would like to cancel his policy at this time we can offer him a prorated refund for the unused portion of the current policy month as is our policy for any policy holder I am sorry if the exclusions and policy terms and conditions were not clear at the start of the policy and Mr [redacted] should feel free to call us with any questions, concerns, or if he would like to cancel his policy I hope this addresses the complaint in its entirety and feel free to contact me directly with any issues Best regards, [redacted] ***, RVT Claims Manager, Embrace Pet Insurance v
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear below I've personally concluded that her foot-licking was a reaction to chemical treatments on the grass at the apartments where I had lived at the timeSince moving, I have noticed no licking of the feet at allDespite his excessive treatment for allergic conditions, my dog's sire licks his feet excessively due to a developing benign tumor on his footGiven the genetics, it's possible she may have been gradually developing one unseen as wellThere are many possible explanations for her conditions at the time of that visit, and allergies were discussed as a possible concern in the future during the visit, but it was in no way conclusively determined at that timeThe cause of her yeast infection in April, was inconclusive and may have been due to inadequate drying after bathingAfter some changes in her grooming, her symptoms went away and were not seen againWhat she experienced in August was dramatically different from what she had experienced in April, with widespread hair loss and lesions across her neck and faceTHIS was determined to be an allergic reactionThere was no conclusive determination prior to the policy that she was experiencing any allergic reactionsI DID know prior to the policy that she could potentially develop these in the very near future based on her sire's recent diagnoses and treatment (he had hair loss and lesions covering his entire body.) It is because of the genetic connection creating a concern of potential need that I sought coverageThere was no need prior to coverageBy rejecting my claims, considering my financial status, the rate at which her sire's condition progressed, and the fact that no other insurance would cover her claims now that she's definitively experienced allergic symptoms, Embrace is dooming her to a miserable existence for the remainder of her lifespanPunishing the consumer for being hyper-vigilant of his pet's health prior to coverage is a VERY poor legacy for a pet insurer Regards, [redacted]
Dear Revdex.com, I am happy to address Mr [redacted] ’s concerns and explain the details on why the claims and appeal were not coveredIt is certainly not in order to be fraudulent or “find any justification to deny”, as Mr [redacted] has stated The issue in this case is not one of an additional, hidden waiting period, but one of a pre-existing conditionOur policy states no dermatological conditions can be covered if any dermatological conditions were noted before the start of the policy until dermatological conditions have been clear for monthsThe following excerpts are from the policy terms and conditions: Part I- Definitions Dermatological Condition means an Illness related to your Pet’s skin and is deemed to include ear infections and skin lumps but not conjunctivitis or parasitic infestations Part I- Exclusions iIf your pet showed clinical signs of any dermatological condition prior to the end of the waiting period, your pet must be free of any dermatological conditions for twelve (12) consecutive months before any dermatological conditions may be covered again [redacted] ’s owner has already stipulated that a dermatological condition did occur before the start of the policy, meaning we are unable to cover any dermatological conditions until [redacted] has been free of other dermatological conditions for months I will address Mr [redacted] ‘s concerns in order “First, an ear infection is not dermatological.” The inside of the ears are covered in a layer of dermis and most vets will agree they are often affected like other exposed parts of the skinWe include ear infections in our definition of dermatological specifically to clear up any confusion on how we treat the ears “Second, I was given no notification of such a waiting period.” As I have already explained above it is not really a waiting period, but an exclusion due to a pre-existing conditionUpon signup for this policy, on 8/5/Mr [redacted] was offered a medical history review once medical records were receivedHe did not respond with a request for a reviewHe was also informed in the same email and another email on 8/6/the medical history is collected but remains on file until we receive [redacted] ’s first claimWe would not have any way of knowing what pre-existing conditions exist until the history is reviewed for the first claim unless a history review was requested by the pet parentIn this case, no review was requested “Third, the vet specifically documented the complete lack of any relation of the conditions the claims were submited for to the pre-policy dermatitis.” With the policy terms and conditions written the way they are, the pre-existing dermatological condition does not need to be ‘related’ to the claimed dermatological condition, they just have to both be dermatological in nature as defined by the policy to apply to this exclusion The dermatological exclusion for [redacted] is temporary and can expire as long as he is clear of dermatological conditions for months Due to the above factors we are not able to cover the claims and comply with Mr [redacted] ’s request to “pay the claims in the amount of $as submitted.” In regard to his other request, to “refund all premiums paid,” we can only do something of this nature within the first days of the start of the policyMr [redacted] ’s policy has been in place since 7/19/This is also outlined in our policy terms and conditions: Part VII- Other terms and conditions Cancellation refundUpon cancellation, you may be entitled to a premium refundIf you provide us written notice of cancellation within thirty (30) days of the effective date and you have made no claim, we will refund the premium you paid us and the policy will be cancelled If Mr [redacted] would like to cancel his policy at this time we can offer him a prorated refund for the unused portion of the current policy month I am sorry if the exclusions and policy terms and conditions were not clear at the start of the policy and Mr [redacted] should feel free to call us with any questions, concerns, or if he would like to cancel his policy at this time I hope this addresses the complaint in its entirety and feel free to contact me directly with any issues Best regards, [redacted] ***, RVT Claims Manager, Embrace Pet Insurance
Dear Ms.***
Thank you for advising us of *** ***’s complaint; ID ***. I do understand the pet parent’s frustration,
but I’m afraid we are unable to provide coverage for his claims or to provide
him a full refund as he requestedThe policy terms and
conditions clearly
define his pet as having a pre-existing condition that has not remained
resolved for consecutive months and Mr*** has received coverage for his
pet for other coverable conditions
Mr***’s pet, ***, was noted to have undiagnosed
diarrhea prior to the purchase of the policy making the clinical sign of
diarrhea and any related conditions a pre-existing condition. The policy considers this a temporary
exclusion and will provide coverage for the condition as long as *** is free
of the clinical signs and any related conditions for consecutive
months. Unfortunately, *** had
recurrent bouts of diarrhea and has been unable to meet the month
requirement.
***’s policy began on 1/6/and had a fourteen (14) day waiting
period for all illnesses and accidents, which ended on 1/19/14. The policy defines a pre-existing condition
as: an illness or injury that first occurred or showed Clinical Signs prior to
the end of the Waiting Period for your Pet and any related conditions
***’s medical history documented diarrhea on 7/17/and
on 8/1/noted “has always had loose stools”.
Diagnostics to determine the cause of the diarrhea and loose stool had
not been performed, so the policy considers this to be an undiagnosed clinical
sign. *** was noted to have
diarrhea/loose stools again on 2/16/14, 2/17/14, 2/21/and 3/3/14. The diagnosis presented on the claim form for
the 3/3/claim noted the pet to have giardia, which is an intestinal parasite
that causes diarrhea. The claims for
giardia cannot be covered because *** had undiagnosed diarrhea prior to the
start of the policy making diarrhea and any related conditions, such as
giardia, pre-existing and not coverable unless resolved for consecutive
months
The policy cannot provide a full refund of premium paid
because Mr*** did have coverage for his pet, ***, for any condition deemed
coverable by the policy terms and conditions.
The policy reimbursed the full amount agreed upon for his wellness
coverage, and provided coverage with reimbursement for two illness claims that
were submitted
I would also like to address Mr***’s reference to
reducing the waiting period of the policy.
In addition to the fourteen (14) day waiting period, the policy has a six
(6) month waiting period for orthopedic conditions. There is no option to waive the fourteen (14)
day waiting period but pet parents due have the option to reduce the six (6)
month orthopedic waiting periodThe orthopedic waiting period can be reduced from
six (6) months down to fourteen (14) days or the date of the orthopedic
examination if this occurs after the fourteen (14) day waiting period The policy requires an orthopedic examination
to occur after the start date of the policy.
A specific form must be completed by the examining veterinarian and sent
to Embrace. To date, Embrace has not
received the orthopedic examination form to reduce this waiting period. Mr*** submitted a claim for an orthopedic
condition during this six (6) month orthopedic waiting period. This claim was not coverable as the condition
was found prior to the end of the orthopedic waiting period making the
condition pre-existing
I’m sorry that we cannot provide coverage for Mr***’s
claims or provide him with a full refund.
The policy does provide a pro-rated refund amount, which Mr***
received when he cancelled, but cannot provide a full refund because coverage
was in effect. The policy would and did
provide coverage for conditions not noted to be present prior to the start of
the policy or within either of the policy’s waiting periodsI would have hoped
Mr*** could see the benefit of the policy and the many conditions that would
have coverage; however, I understand his frustration with not having some of
his claims covered and his decision to cancel
Please feel free to contact me if you have any questions or need additional information
Best regards,
*** ***
senior claims adjuster
(800) 511-
EmbracePetInsurance.com | Facebook
| Twitter
Hello again
Revdex.com and Ms***,
I am happy
to keep explaining this situation until Ms*** is more satisfied
We are not
permitted to assume an onset date of an illnesses and, as such, we did not
assume anything in this caseAs I have noted in my prior responses the medical
notes from 1/15/stated and I quote “Presented for lameness of RF (right
front) legDuration > month.” Also, the veterinarian’s appeal letter
noted and I quote, “During my exam I asked the owner the duration of condition,
the owner stated it was approximately month”Therefore, no assumptions were
madeWe took the onset of this lameness directly from the two written sources
we were provided withBoth sources agree the onset of this lameness was before
the completion of the policy orthopedic waiting period
I understand
Ms*** is not happy with the result of her claim and appeal, however, I
believe I have addressed all of the points she has brought up in this and my
previous responses
Please let
me know if there is any other information you need from Embrace
*** ***
Claims
Manager
Embrace Pet
Insurance
I am happy to address the situation concerning C***’s
lameness claims for Revdex.com review
Ms***’s policy started on 7/1/14, and included a
month orthopedic waiting period that expired on 1/1/This waiting period can
be reduced to days with completion of an orthopedic exam by a
veterinarian after
the purchase of the policyThis is exam is optional and we do not have records
of this exam on file for C*** so his waiting period stood to expire on 1/1/
We are only able to make decisions for coverage on what
information we are provided with from the veterinarianIn this case, the
medical records for the first visit for lameness on 1/15/state “Presented
for lameness of RF (right front) legDuration > month.” This puts the
onset of the lameness into the orthopedic waiting period since that waiting
period did not end until 1/1/The policy terms and conditions state any ab
signs noted by the pet parent or
veterinarian within the defined waiting periods will create exclusions of
coverage in the policyThe following is an excerpt from the policy terms and
conditions:
Pre-existing Condition(s) means:
aa Chronic Condition observed by you (the policy holder) or your Veterinary
Provider prior to the end of the Waiting Period for your Pet(s) and any related
conditions; or ban Illness or Injury that first occurred or showed Clinical
Signs prior to the end of the Waiting Period for your Pet and any related
conditions. Undiagnosed conditions with
the same Clinical Signs as those in aor babove are also considered
pre-existing
Ms*** did appeal the claims, however, the appeal
information from DrB*** confirmed the onset of the clinical signs of the
lameness were approximately one month and the appeal was not successfulThe
letter from DrB*** did also state the condition is not pre-existing since
he had not previously diagnosed it, but as our terms and conditions state, that
is not needed for a condition to be pre-existingA pre-existing condition as
defined by the policy is any condition showing signs during a waiting period or
before the start of the policy
Additionally, for the appeal our senior claims adjuster
reviewed all of the notes from ** StateWe did not have those notes prior to the
appealThose notes also have the duration of the lameness as one month,
putting the onset in the orthopedic waiting period
Unfortunately, due to the above evidence and the policy
restrictions, I am unable to acquiesce to the stated desired settlement to
cover the lameness condition for C***
*** ***
Claims
Manager
Embrace Pet
Insurance
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below
[To assist us in bringing this matter to a close, we would like to know your view on the matter.]
Regards,
*** ***
I am sorry for Ms. [redacted]’s frustration. The main points
of her frustration seems to be a delay in processing her claim and the
inconsistency in what information she was given about the timeline for claims
processing.
I will first address the timeline itself of this claim....
The
claim documentation was received into our fax system on 10/15/14, was processed
and setup as a claim on 10/20/14 and was processed on 10/29/14. We are experiencing some delays at this
time due to a systems upgrade that has put some kinks into our efficiency,
however, this claim was processed within the 8-10 business day window Ms.
[redacted] was given on her first contact for this claim.
The second issue is one of consistency with the time line
estimates. I agree the outline of what Ms. [redacted] was told through the
contact center was inconsistent. We are experiencing some delays of our normal processing
times, and had not updated our ‘claim received’ email to reflect this. We also
had not updated our estimate for the customer contact group to give to our policy
holders when they called to inquire on their claims. We have addressed these
issues in the following ways: the email now accurately reflects our current
processing time (20-25 business days) while we endeavor to catchup with our
current backlog of claims, and we have also instituted more training for our
customer contact center group in regards to estimates for claims.
[redacted], RVT
Claims Manager
Embrace Pet Insurance
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.
I've personally concluded that her foot-licking was a reaction to chemical treatments on the grass at the apartments where I had lived at the time. Since moving, I have noticed no licking of the feet at all. Despite his excessive treatment for allergic conditions, my dog's sire licks his feet excessively due to a developing benign tumor on his foot. Given the genetics, it's possible she may have been gradually developing one unseen as well. There are many possible explanations for her conditions at the time of that visit, and allergies were discussed as a possible concern in the future during the visit, but it was in no way conclusively determined at that time. The cause of her yeast infection in April, 2014 was inconclusive and may have been due to inadequate drying after bathing. After some changes in her grooming, her symptoms went away and were not seen again. What she experienced in August was dramatically different from what she had experienced in April, with widespread hair loss and lesions across her neck and face. THIS was determined to be an allergic reaction. There was no conclusive determination prior to the policy that she was experiencing any allergic reactions. I DID know prior to the policy that she could potentially develop these in the very near future based on her sire's recent diagnoses and treatment (he had hair loss and lesions covering his entire body.) It is because of the genetic connection creating a concern of potential need that I sought coverage. There was no need prior to coverage. By rejecting my claims, considering my financial status, the rate at which her sire's condition progressed, and the fact that no other insurance would cover her claims now that she's definitively experienced allergic symptoms, Embrace is dooming her to a miserable existence for the remainder of her lifespan. Punishing the consumer for being hyper-vigilant of his pet's health prior to coverage is a VERY poor legacy for a pet insurer.
Regards,
[redacted]
Dear Revdex.com,
I am happy to address Mr. [redacted]’s concerns and explain
the details on why the claims and appeal were not covered. It is certainly not
in order to be fraudulent or “find any justification to deny”, as Mr. [redacted]
has stated.
The issue in this case is not one of an...
additional, hidden
waiting period, but one of a pre-existing condition. Our policy states no
dermatological conditions can be covered if any dermatological conditions were
noted before the start of the policy until dermatological conditions have been
clear for 12 months. The following excerpts are from the policy terms and
conditions:
Part I- Definitions
15.
Dermatological Condition means
an Illness related to your Pet’s skin and is deemed to include
ear infections and skin lumps but not conjunctivitis or parasitic infestations.
Part I-
Exclusions
1. I. If
your pet showed clinical signs of any dermatological condition prior to the end
of the waiting period, your pet must be free of any dermatological conditions
for twelve (12) consecutive months before any dermatological conditions may be
covered again.
[redacted]’s owner has already stipulated that a
dermatological condition did occur before the start of the policy, meaning we
are unable to cover any dermatological conditions until [redacted] has been free
of other dermatological conditions for 12 months.
I will address Mr. [redacted]‘s concerns in order.
“First, an ear infection is not dermatological.” The inside
of the ears are covered in a layer of dermis and most vets will agree they are
often affected like other exposed parts of the skin. We include ear infections
in our definition of dermatological specifically to clear up any confusion on
how we treat the ears.
“Second, I was given no notification of such a waiting
period.” As I have already explained
above it is not really a waiting period, but an exclusion due to a pre-existing
condition. Upon signup for this policy, on 8/5/14 Mr. [redacted] was offered a
medical history review once medical records were received. He did not respond
with a request for a review. He was also informed in the same email and
another email on 8/6/14 the medical history is collected but remains on file
until we receive [redacted]’s first claim. We would not have any way of knowing
what pre-existing conditions exist until the history is reviewed for the first claim
unless a history review was requested by the pet parent. In this case, no
review was requested.
“Third, the vet specifically documented the complete lack
of any relation of the conditions the claims were submited for to the
pre-policy dermatitis.” With the policy terms and conditions written the way
they are, the pre-existing dermatological condition does not need to be ‘related’
to the claimed dermatological condition, they just have to both be dermatological
in nature as defined by the policy to apply to this exclusion.
The dermatological exclusion for [redacted] is temporary and
can expire as long as he is clear of dermatological conditions for 12 months.
Due to the above factors we are not able to cover the
claims and comply with Mr. [redacted]’s request to “pay the claims in the amount
of $341.13 as submitted.”
In regard to his other request, to “refund all premiums
paid,” we can only do something of this nature within the first 30 days of the start
of the policy. Mr. [redacted]’s policy has been in place since 7/19/14. This is
also outlined in our policy terms and conditions:
Part
VII- Other terms and conditions
3. Cancellation refund. Upon
cancellation, you may be entitled to a premium refund. If you provide us
written notice of cancellation within thirty (30) days of the effective date
and you have made no claim, we will refund the premium you paid us and the
policy will be cancelled.
If Mr. [redacted] would like to cancel his policy at this
time we can offer him a prorated refund for the unused portion of the current
policy month.
I am sorry if the exclusions and policy terms and conditions
were not clear at the start of the policy and Mr. [redacted] should feel free to
call us with any questions, concerns, or if he would like to cancel his policy at this time.
I hope this addresses the complaint in its entirety and
feel free to contact me directly with any issues.
Best regards,
[redacted], RVT
Claims Manager,
Embrace Pet Insurance
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.First, Ms. [redacted] says, "it is not really a waiting period, but an
exclusion due to a pre-existing condition". Well if I have to wait 12 months, to me, that is a waiting period.Second, she can get into the semantics of what is or isn't dermatological, but the vet did submit documentation to Embrace that clearly stated the ear infection had nothing to do with any other type of skin condition, and should not be considered pre-existing. For the record, the dog had an allergic reaction causing irritation on the bottom of her paws and an infected incision from the spaying surgery. The ear infection occurred as a result of water getting in the ear from a bath at a grooming facility.Third, she references email to me on 8/5. The only email I have that resembles anything like what she is referring to was actually on 8/18 about an orthopedic report card. I admittedly did not send that to my vet to complete, but that is not related to this issue.Fourth and most importantly, they are standing on the grounds of "Our policy states no dermatological conditions
can be covered if any dermatological conditions were noted before the start of
the policy." This is not the case. The policy started on 7/19. The condition that Embrace is considering pre-existing occurred on 7/14 but was only brought to their attention on 9/22 when I erroneously submitted a claim for the 7/14 vet visit because I had forgotten that was prior to the policy being in effect. So Embrace in fact did not note any dermatological condition prior to the start of the policy. Per their policy exclusions, "clinical signs of any dermatological condition
prior to the end of the waiting period" - the waiting period would have been 7/19-8/2. That should eliminate anything prior to 7/19. They bound the policy on 7/19 with receipt of medical history from the vet. So again, I stand by my complaint that either the claims should be paid or my premiums refunded, less the one $38 claim that was paid.
[To assist us in bringing this matter to a close, we would like to know your view on the matter.]
Regards,
[redacted]
Dear Revdex.com,
I have reviewed Mr [redacted]’s response and
would like to discuss his rebuttal statements below.
This case all boils down to the fact that
dermatological condition occurred before the start of the policy. Mr. [redacted]
himself acknowledges this. The policy is clear that if any dermatological condition happens before the start of the
policy, no matter the cause, (water in the ear, contact dermatitis from a
shampoo, etc.) no dermatological
conditions can be covered until all
dermatological conditions are clear for a full 12 months. Relationship between
the conditions does not have to exist to fit this clause of the terms and
conditions so the veterinarian's statement of non-relation in this case is immaterial.
Part I- Definitions
15.
Dermatological Condition means
an Illness related to your Pet’s skin and is deemed to include
ear infections and skin lumps but not conjunctivitis or parasitic infestations.
Part
I- Exclusions
1. I. If
your pet showed clinical signs of any dermatological condition prior to
the end of the waiting period, your pet must be free of any
dermatological conditions for twelve (12) consecutive months before any
dermatological conditions may be covered again.
His reasoning about why we found out about the
pre-existing dermatological condition, his erroneous claim, is a non-starter.
We routinely request all medical history before we process the first illness
claim so we can learn of any possible pre-existing conditions. Whether the
claim had been submitted or not, the prior dermatological conditions were
recorded in the medical history and were listed as pre-existing conditions upon
our review.
Additionally, Mr. [redacted] states, “Per their
policy exclusions, "clinical signs of any dermatological condition prior
to the end of the waiting period" - the waiting period would have been
7/19-8/2. That should eliminate anything
prior to 7/19.” The date of 7/19/14 is
prior to the end of the waiting period. The policy does not say only things in the waiting period are
pre-existing. It says any illness or abnormality before (prior) the end of the waiting
period will be deemed pre-existing conditions. We routinely review the last 12
months of medical history and make note of pre-existing conditions, not just
what occurred in the first 14 days of the policy. This practice is standard for
every pet insurance company, though some review 18 or 24 months of medical
history.
Again, I assert [redacted]’s claim was processed appropriately
according to the policy terms and conditions, and I therefore cannot offer Mr.
[redacted] a full refund as per his request.
If Mr. [redacted] would like to cancel his policy
at this time we can offer him a prorated refund for the unused portion of the
current policy month as is our policy for any policy holder.
I am sorry if the exclusions and policy terms
and conditions were not clear at the start of the policy and Mr. [redacted]
should feel free to call us with any questions, concerns, or if he would like
to cancel his policy.
I hope this addresses the complaint in its
entirety and feel free to contact me directly with any issues.
Best regards,
[redacted], RVT
Claims Manager,
Embrace Pet Insurance
v
I am happy to address Mr. [redacted]’s concerns and explain
the details on why his pet [redacted]’s claims were not covered.
To begin, we do cover genetic conditions (and all other conditions)
as long as there are no signs of them before the start of the policy. If there
is a clinical sign of an...
issue before the start of the policy, it is considered
a pre-existing condition. This is true of all pet insurance companies.
[redacted] had a visit on 4/24/14 where her vet described her to
have pruritus (itching), a severe ear infection, and yeast dermatitis in skin
folds and on her chin. On 5/28/14 she was noted to be licking her feet which
can be a sign of itchy feet and allergies. The policy was purchased on 7/14/14,
and the policy 14 day waiting period was complete on 7/29/14. On 8/8/14 [redacted] was
seen for an ear infection, skin fold dermatitis and was ultimately diagnosed
with atopy.
Our policy terms and conditions concerning this issue are as
follows:
Part I- Definitions
15. Dermatological Condition means an Illness related to
your Pet’s skin and is deemed to include ear infections and skin lumps but not
conjunctivitis or parasitic infestations.
Part I- Exclusions
1. I. If
your pet showed clinical signs of any dermatological condition prior to the end
of the waiting period, your pet must be free of any dermatological conditions
for twelve (12) consecutive months before any dermatological conditions may be
covered again.
The exclusion section of the terms and conditions above specifies
any dermatological condition noted before the start of the policy creates an
exclusion for any dermatological condition unless the pet can be free of
dermatological conditions for a full 12 months. This did not happen in [redacted]’s
case. She had dermatological issues in April, again in May, and was diagnosed
with allergies/ atopy in August.
We did receive a letter from Mr. [redacted]’s veterinarian on
2/19/15 and it is in the process of being setup, however, I do not expect the
appeal will be successful in overturning [redacted]’s claims in light of the clinical
signs of dermatological issues seen before the start of the policy.
As for the desired settlement, if Mr. [redacted] would like to
cancel his policy we can offer him a prorated refund for the unused portion of
this month’s premiums as we would for any pet parent wishing to cancel his
policy. I am sorry I cannot offer more, but we have upheld the policy terms and
conditions as stated.
Mr. [redacted] should feel free to call us with any questions,
concerns, or if he would like to cancel his policy.
I hope this addresses the complaint in its entirety and feel
free to contact me directly with any issues.
Best regards,
[redacted], RVT
Claims Manager,
Embrace Pet Insurance
Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.This is an assumption made by EMBRACE. I never told my VET that he was lame for over a month. He had just started limping for about a week before I brought him in to the point of no relief with rest. I would never let my pet go for a month liming without seeking medical attention. He has other issues as a pup, one with his tail and lump on back foot that made him limp from time to time but it WAS NOT because of his shoulder. They are trying to find an excuse not to pay this claim. My Vet even sent a letter that this was not pre-existing in his medical opinion. If C[redacted] had any prior history of limping it would have been noted in his medical history during prior Vet appointments and Wellness visits. They need to pay this claim as they are denying this on an assumption.
He is my dog and I know this was NOT pre-existing!Regards,[redacted]