It is our goal to provide a positive experience for pet parents who cover their pet with a policy from our company. On initial review of the claimant's medical records there was an indication that the claimant had purchased a new policy in September of 2017 with another pet insurance...
carrier. Our claims administrators requested information regarding the new policy from the claimant to determine what benefits would be payable based on the Other Insurance clause contained in the claimant's policy with our company. This information was not received from the claimant. Upon further review of the Other Insurance clause it was determined that, since the claimant was insured with our company prior to writing a policy with another company, the policy already in place (our policy) would be the primary policy on this claim. The claim has been processed and a check has been issued to the claimant. We apologize for any inconvenience the delay in paying the claim may have caused the complainant.
We have pulled and reviewed the claim including all corresponding medical records. We do not have the statement from the veterinarian stating that the two issues are unrelated as suggested by the policyholder. The records from the veterinarian that we do have indicate that the pet...
recently had surgery and has been scratching and rubbing the eye. The vet's notes also specify that the owner reports that the eye has become more cloudy. Based on the information we have been provided by the treating veterinarian, we believe that the claim was appropriately denied per the policy terms. If you have additional information from the veterinarian to submit or would like to discuss the information we have received, please contact me directly at [redacted] Sincerely,[redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution would be satisfactory to me. I will wait for the business to perform this action and, if it does, will consider this complaint resolved.
Regards,
[redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted]. While I realize this resolution should be satisfactory to me, I would like their false advertising to be addressed. How can they possibly use a line on their website saying they pay 90% of all veterinary bills when they don't cover anything routine and deny everything else? This seems like a scam to anyone who makes the mistake of buying their insurance.
They are now also claiming a per incident limit, and are only going to send $1,000 of the entire amount I requested. I believe they have agreed to resolve this claim for a bare minimum and with restrictions. How can this be a legal way to do business?
Regards,
[redacted] %
We regret that claims were not settled as quickly as we would like. Each policy that is issued by PetFirst's states that claims will be settled within 30 days of receipt of the information required to process the claim. The outstanding claims noted by the policyholder have now been...
settled. If there are any questions about the claims themselves or the settlement time, please contact me directly at [redacted] Sincerely,[redacted]
Based on a detailed review of this claim as well as the claims history of this pet, it is our determination that this claim should have been paid as a separate incident. As such, we have approved and re-submitted the claim for payment. A check will be mailed to the insured within the...
Ms. [redacted] has a PAWS plan with PetFirst. This plan covers accidents and illnesses and does not cover routine examinations as listed in her policy exclusions.
EXCLUSIONS AND LIMITATIONS
Beyond the limits and exclusions pertaining to specific coverages under this policy that have...
thus far been set forth above, this policy will not pay for costs “you” incur for:
14. Routine examinations, routine tests or screens, vaccines, teeth cleaning or polishing.
The claim Ms. [redacted] is referring to in this complaint was closed because PetFirst did not receive the required documents. We include in the policy packet a check list that lists what is needed to process a claim.
Attach all medical treatment records for the claimed incident?
If this is your pet’s first accident or illness claim, please provide 12 months of medical records (i.e. doctor’s notes; prior to and including the incident date)
If your pet is less than 12 months of ages, include all vet visits
If this is not your first accident/illness claim, but is a new incident, please include the medical records related to the new claim
If you recently adopted, please include adoption paperwork
PetFirst has made multiple attempts to retrieve the required documents for Ms. [redacted]. PetFirst sent an email to Ms. [redacted] explaining what documents we were missing. When PetFirst did not receive the information from Ms. [redacted], PetFirst called and faxed, on separate occasions, the Veterinarian’s office asking for the medical records. The Veterinarian’s office sent us prior invoices but that is not what we had requested. We re-requested, per the Veterinarian’s office, to send the fax request again asking for the medical records, but as of today PetFirst still does not have the medical records. The medical records give PetFirst the assessment and plan of action for the pet and is needed to properly code the treatment.
Ms. [redacted] called PetFirst customer service 3 times and was told each time that medical records were needed to be able to process the claim. Medical records were explained to Ms. [redacted] as being the doctor notes that would be in the pets file.
Ms. [redacted]’s claim can be re-opened if the medical records are received.
PetFirst apologizes for the confusion and has made every effort to obtain the medical records that are required to continue to process the claim.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
The claim was denied because in [redacted] the his primary care veterinarian thought that [redacted] had an arrhythmia and referred him to the cardiologist. The cardiologist after running several test EKG, holter and Eco cardiogram did not find any arrhythmia.
Also we find it deceiving that the reason we upgraded the coverage of the policy was because one of your agents called us and said that it was better to get a better coverage because [redacted] was getting old and we accepted. She switch the policy for us over the phone without saying that if we started this new policy all previous covered illnesses would become preexistent. We didn't saw the general terms and conditions until after the policy was already in effect.
Regards,
[redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
Regards,
[redacted]
They never contacted me nor the vet that I use. And we sent everything they had asked for. It is irritating that they can not receive the actual medical records but seem to receive the invoices. Which I and the vet sent exactly the same way they asked us to. We sent everything and have received nothing.
Unfortunately, this seems to be a case of miscommunication. At the time of purchase, Ms. F. elected to forego the complimentary 30-day policy and instead opted to purchase a Premier $2k policy, scheduled to be active on 2/16/17. We apologize for any misunderstanding on our part as it is always our...
goal to sell clear, comprehensive and value-oriented policies to our customers. Because of the misunderstanding, we have reached out to Ms. F., letting her know that her policy has been cancelled and we will be sending her the full refund amount as requested.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution would be satisfactory to me. I will wait for the business to perform this action and, if it does, will consider this complaint resolved.
Regards,
[redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
[redacted]
Regards,
[redacted]
Our goal at PetFirst is to provide a positive experience for our policyholders even though, at times, claims may be denied due to policy exclusions or other provisions. This insured initiated a pet insurance policy using our on-line system. There are prompts in this process that direct...
the customer's attention to policy exclusions and provisions. In this case, however, the insured has filed two claims. One claim was denied because it was below the insured's deductible amount. The other claim has been closed because we did not receive an itemized invoice for the treatment date of service. PetFirsts Customer Service is going to reach out to this insured to see if we can obtain the information needed to re-open and process the claim. We will also help the insured to understand the policy provisions and the claims process.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
Their own employee told me on the phone that they continue to add exclusions every year. I called to review this policy every year before renewing and was told that my coverage was good and included accident coverage. Again this is an accident not just a condition that developed the vet documented on the claim they are refusing. I will be glad to provide a copy of his notes on the claim. This company is an Internet scam they are really a company called something like American alternative insurance based in New Jersey representing themselves under a different name in your state and doing business exclusively over the Internet and phone misrepresenting the coverage and increasing the price every year. I want the amount they said they would cover $1,000 per incident and I want the money they collected for my two dogs since 2012 while misrepresenting coverage. I am very concerned about this company preying on senior citizens. You should be also.
Regards,
[redacted]
With regard to the above referenced complaint, we submit a summary of the claims handling issues addressed by the complainant.
The insured has had a policy with PetFirst covering her pet, [redacted], since 2008. The original policy, [redacted] was written under our Preferred...
policy plan.
PetFirst received a claim for [redacted], date of loss June 30, [redacted]. The claim was for Arrhythmia/Syncope and totaled $1,995.00. Check No. [redacted] was issued to the insured on August 6, [redacted] in the amount of $1,705.50.
Effective December 27, [redacted] the insured changed the policy covering [redacted] to a Lifetime Medical $10K plan.
Effective December 27, 2013 the insured changed the policy covering [redacted] to a lifetime Medical $5K plan.
The insured submitted a claim to PetFirst for [redacted] with dates of loss October 24, [redacted], November 10, [redacted] and December 2, [redacted] for charges related to subsequent treatment for Arrhythmia/Syncope. This claim was denied due to the chronic condition and its presence prior to the effective date of the Lifetime policy implementation.
The Lifetime policy contains a rule under the General Conditions section of the Lifetime form addressing the application of coverage to claims when an insured transfers their policy to a policy with higher limits which states:
D. In the event of the insured opting to transfer the insured's pet to a program with higher benefits, the maximum benefit payable with respect to an illness or injury will be restricted to the maximum benefit payable under the policy that applied during the period in which such illness(es) or injury was first noted; diagnosed; or treated. If the level of coverage is lowered, the lower maximum benefits shall apply. The addition of any new pet(s) or endorsements/riders to an active policy shall result in a 15 day waiting period before that coverage becomes effective.
Therefore, due to the fact that this illness existed prior to the effective date of the Lifetime policy coverage would be provided per the conditions of the Preferred policy that was in existence when the condition was first diagnosed. Per the conditions of the Preferred policy, chronic conditions are excluded and there would have been no coverage for this claim. Below is the Preferred policy definition of “chronic” and a copy of the exclusion.
"Chronic conditions" are injuries and/or illness that are likely to reappear and are unlikely to be resolved
EXCLUSIONS AND LIMITATIONS
12. Continuous coverage of "chronic conditions" and "long-term conditions" that manifested in a previous Pet Insurance Policy with "us".
We do understand that our policyholder not been satisfied with our adjudication of this claim. Their satisfaction is very important to us and we wish that this matter could be settled amicably. However based on facts of this claim as we understand them, we feel that we have followed the terms and conditions of this policy in an appropriate manner. If there is any additional information that the policyholder can supply, we will be happy to review it.
It is always our goal to pay claims in a hassle-free manner and unfortunately, in this situation, we fell short. After further review of the documentation sent to us by [redacted] we were able to locate and interpret the package of services purchased and are processing the claim in question. We have...
reached out to [redacted], letting her know that we will be refunding her for these services.
It is always our goal to pay claims in a hassle-free manner and unfortunately, in this situation, there was some confusion around the specific services and the costs associated in the claim. After further review of the documentation sent to us by Ms. *., we were able to interpret the package of...
services purchased and are processing the claim in question. We will reach out to Ms. *, letting her know that we will be refunding her for these services.
It is our goal to provide a positive experience for all of our policyholders. It appears that there was a misunderstanding regarding the definition of pre-existing conditions. As a result of the review of this file, the claim was re-adjusted and a check was mailed to the policyholder....
Our policyholders are valuable to our business. No personal information is shared with any third party. We appreciate the opportunity to serve you. [redacted] MBA, CPCU, CIC, ACP Director of Compliance and Risk Management
It is our goal to provide a positive experience for pet parents who cover their pet with a policy from our company. On initial review of the claimant's medical records there was an indication that the claimant had purchased a new policy in September of 2017 with another pet insurance...
carrier. Our claims administrators requested information regarding the new policy from the claimant to determine what benefits would be payable based on the Other Insurance clause contained in the claimant's policy with our company. This information was not received from the claimant. Upon further review of the Other Insurance clause it was determined that, since the claimant was insured with our company prior to writing a policy with another company, the policy already in place (our policy) would be the primary policy on this claim. The claim has been processed and a check has been issued to the claimant. We apologize for any inconvenience the delay in paying the claim may have caused the complainant.
We have pulled and reviewed the claim including all corresponding medical records. We do not have the statement from the veterinarian stating that the two issues are unrelated as suggested by the policyholder. The records from the veterinarian that we do have indicate that the pet...
recently had surgery and has been scratching and rubbing the eye. The vet's notes also specify that the owner reports that the eye has become more cloudy. Based on the information we have been provided by the treating veterinarian, we believe that the claim was appropriately denied per the policy terms. If you have additional information from the veterinarian to submit or would like to discuss the information we have received, please contact me directly at [redacted] Sincerely,[redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution would be satisfactory to me. I will wait for the business to perform this action and, if it does, will consider this complaint resolved.
Regards,
[redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted]. While I realize this resolution should be satisfactory to me, I would like their false advertising to be addressed. How can they possibly use a line on their website saying they pay 90% of all veterinary bills when they don't cover anything routine and deny everything else? This seems like a scam to anyone who makes the mistake of buying their insurance.
They are now also claiming a per incident limit, and are only going to send $1,000 of the entire amount I requested. I believe they have agreed to resolve this claim for a bare minimum and with restrictions. How can this be a legal way to do business?
Regards,
[redacted] %
We regret that claims were not settled as quickly as we would like. Each policy that is issued by PetFirst's states that claims will be settled within 30 days of receipt of the information required to process the claim. The outstanding claims noted by the policyholder have now been...
settled. If there are any questions about the claims themselves or the settlement time, please contact me directly at [redacted] Sincerely,[redacted]
Based on a detailed review of this claim as well as the claims history of this pet, it is our determination that this claim should have been paid as a separate incident. As such, we have approved and re-submitted the claim for payment. A check will be mailed to the insured within the...
next two weeks.
Ms. [redacted] has a PAWS plan with PetFirst. This plan covers accidents and illnesses and does not cover routine examinations as listed in her policy exclusions.
EXCLUSIONS AND LIMITATIONS
Beyond the limits and exclusions pertaining to specific coverages under this policy that have...
thus far been set forth above, this policy will not pay for costs “you” incur for:
14. Routine examinations, routine tests or screens, vaccines, teeth cleaning or polishing.
The claim Ms. [redacted] is referring to in this complaint was closed because PetFirst did not receive the required documents. We include in the policy packet a check list that lists what is needed to process a claim.
Attach all medical treatment records for the claimed incident?
If this is your pet’s first accident or illness claim, please provide 12 months of medical records (i.e. doctor’s notes; prior to and including the incident date)
If your pet is less than 12 months of ages, include all vet visits
If this is not your first accident/illness claim, but is a new incident, please include the medical records related to the new claim
If you recently adopted, please include adoption paperwork
PetFirst has made multiple attempts to retrieve the required documents for Ms. [redacted]. PetFirst sent an email to Ms. [redacted] explaining what documents we were missing. When PetFirst did not receive the information from Ms. [redacted], PetFirst called and faxed, on separate occasions, the Veterinarian’s office asking for the medical records. The Veterinarian’s office sent us prior invoices but that is not what we had requested. We re-requested, per the Veterinarian’s office, to send the fax request again asking for the medical records, but as of today PetFirst still does not have the medical records. The medical records give PetFirst the assessment and plan of action for the pet and is needed to properly code the treatment.
Ms. [redacted] called PetFirst customer service 3 times and was told each time that medical records were needed to be able to process the claim. Medical records were explained to Ms. [redacted] as being the doctor notes that would be in the pets file.
Ms. [redacted]’s claim can be re-opened if the medical records are received.
PetFirst apologizes for the confusion and has made every effort to obtain the medical records that are required to continue to process the claim.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
The claim was denied because in [redacted] the his primary care veterinarian thought that [redacted] had an arrhythmia and referred him to the cardiologist. The cardiologist after running several test EKG, holter and Eco cardiogram did not find any arrhythmia.
Also we find it deceiving that the reason we upgraded the coverage of the policy was because one of your agents called us and said that it was better to get a better coverage because [redacted] was getting old and we accepted. She switch the policy for us over the phone without saying that if we started this new policy all previous covered illnesses would become preexistent. We didn't saw the general terms and conditions until after the policy was already in effect.
Regards,
[redacted]
 %
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
Regards,
[redacted]
They never contacted me nor the vet that I use. And we sent everything they had asked for. It is irritating that they can not receive the actual medical records but seem to receive the invoices. Which I and the vet sent exactly the same way they asked us to. We sent everything and have received nothing.
Unfortunately, this seems to be a case of miscommunication. At the time of purchase, Ms. F. elected to forego the complimentary 30-day policy and instead opted to purchase a Premier $2k policy, scheduled to be active on 2/16/17. We apologize for any misunderstanding on our part as it is always our...
goal to sell clear, comprehensive and value-oriented policies to our customers. Because of the misunderstanding, we have reached out to Ms. F., letting her know that her policy has been cancelled and we will be sending her the full refund amount as requested.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution would be satisfactory to me. I will wait for the business to perform this action and, if it does, will consider this complaint resolved.
Regards,
[redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
[redacted]
Regards,
[redacted]
Our goal at PetFirst is to provide a positive experience for our policyholders even though, at times, claims may be denied due to policy exclusions or other provisions. This insured initiated a pet insurance policy using our on-line system. There are prompts in this process that direct...
the customer's attention to policy exclusions and provisions. In this case, however, the insured has filed two claims. One claim was denied because it was below the insured's deductible amount. The other claim has been closed because we did not receive an itemized invoice for the treatment date of service. PetFirsts Customer Service is going to reach out to this insured to see if we can obtain the information needed to re-open and process the claim. We will also help the insured to understand the policy provisions and the claims process.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
Their own employee told me on the phone that they continue to add exclusions every year. I called to review this policy every year before renewing and was told that my coverage was good and included accident coverage. Again this is an accident not just a condition that developed the vet documented on the claim they are refusing. I will be glad to provide a copy of his notes on the claim. This company is an Internet scam they are really a company called something like American alternative insurance based in New Jersey representing themselves under a different name in your state and doing business exclusively over the Internet and phone misrepresenting the coverage and increasing the price every year. I want the amount they said they would cover $1,000 per incident and I want the money they collected for my two dogs since 2012 while misrepresenting coverage. I am very concerned about this company preying on senior citizens. You should be also.
Regards,
[redacted]
With regard to the above referenced complaint, we submit a summary of the claims handling issues addressed by the complainant.
The insured has had a policy with PetFirst covering her pet, [redacted], since 2008. The original policy, [redacted] was written under our Preferred...
policy plan.
PetFirst received a claim for [redacted], date of loss June 30, [redacted]. The claim was for Arrhythmia/Syncope and totaled $1,995.00. Check No. [redacted] was issued to the insured on August 6, [redacted] in the amount of $1,705.50.
Effective December 27, [redacted] the insured changed the policy covering [redacted] to a Lifetime Medical $10K plan.
Effective December 27, 2013 the insured changed the policy covering [redacted] to a lifetime Medical $5K plan.
The insured submitted a claim to PetFirst for [redacted] with dates of loss October 24, [redacted], November 10, [redacted] and December 2, [redacted] for charges related to subsequent treatment for Arrhythmia/Syncope. This claim was denied due to the chronic condition and its presence prior to the effective date of the Lifetime policy implementation.
The Lifetime policy contains a rule under the General Conditions section of the Lifetime form addressing the application of coverage to claims when an insured transfers their policy to a policy with higher limits which states:
D. In the event of the insured opting to transfer the insured's pet to a program with higher benefits, the maximum benefit payable with respect to an illness or injury will be restricted to the maximum benefit payable under the policy that applied during the period in which such illness(es) or injury was first noted; diagnosed; or treated. If the level of coverage is lowered, the lower maximum benefits shall apply. The addition of any new pet(s) or endorsements/riders to an active policy shall result in a 15 day waiting period before that coverage becomes effective.
Therefore, due to the fact that this illness existed prior to the effective date of the Lifetime policy coverage would be provided per the conditions of the Preferred policy that was in existence when the condition was first diagnosed. Per the conditions of the Preferred policy, chronic conditions are excluded and there would have been no coverage for this claim. Below is the Preferred policy definition of “chronic” and a copy of the exclusion.
"Chronic conditions" are injuries and/or illness that are likely to reappear and are unlikely to be resolved
EXCLUSIONS AND LIMITATIONS
12. Continuous coverage of "chronic conditions" and "long-term conditions" that manifested in a previous Pet Insurance Policy with "us".
We do understand that our policyholder not been satisfied with our adjudication of this claim. Their satisfaction is very important to us and we wish that this matter could be settled amicably. However based on facts of this claim as we understand them, we feel that we have followed the terms and conditions of this policy in an appropriate manner. If there is any additional information that the policyholder can supply, we will be happy to review it.
It is always our goal to pay claims in a hassle-free manner and unfortunately, in this situation, we fell short. After further review of the documentation sent to us by [redacted] we were able to locate and interpret the package of services purchased and are processing the claim in question. We have...
reached out to [redacted], letting her know that we will be refunding her for these services.
It is always our goal to pay claims in a hassle-free manner and unfortunately, in this situation, there was some confusion around the specific services and the costs associated in the claim. After further review of the documentation sent to us by Ms. *., we were able to interpret the package of...
services purchased and are processing the claim in question. We will reach out to Ms. *, letting her know that we will be refunding her for these services.
It is our goal to provide a positive experience for all of our policyholders. It appears that there was a misunderstanding regarding the definition of pre-existing conditions. As a result of the review of this file, the claim was re-adjusted and a check was mailed to the policyholder....
Our policyholders are valuable to our business. No personal information is shared with any third party. We appreciate the opportunity to serve you. [redacted] MBA, CPCU, CIC, ACP Director of Compliance and Risk Management