Pet's Best Insurance Services

We would like to extend our apologies to our policy holder on this claim and appeal denial. Before the appeal had been finally determined, the policy holder was informed the appeal had been denied. This was incorrect--the appeal had been set to be denied but had not completed the necessary review for a final determination. Shortly after the policy holder's inquiry, the appeal was overturned for the reasons the policy holder stated. It was then that we discovered the policy holder had been misinformed.

We reached out to the policyholder on February 11, 2019 to inform him that we had overturned the appeals in his favor and to offer him a chance to reinstate his policies that he cancelled after being misinformed about the status of his appeal denials. We have not received a response at this time.

Again, we would like to apologize for this misunderstanding and clarify that the policyholder's appeals and claims have been paid at this time.

Hi ***, we understand your concern for coverage. In order to accurately process claims, we request medical records from your veterinarian directly. Medical records indicate the claimed condition originated November 14th, 2017. However, the policy for Fran enrolled January 25th, 2018 with your medical waiting period ending on February 8th, 2018. The claim was denied accordingly based on this information. If you disagree with the claim decision reached with your veterinarian’s notes, you are welcome to file an appeal with supporting documents. We see you have cancelled your policy and wish you and your pets the best.

Hi ***, we understand your concern for coverage. In order to accurately process claims, we request medical records from your veterinarian directly. Medical records indicate the claimed condition originated November 14th, 2017. However, the policy for Fran enrolled January 25th, 2018 with your medical waiting period ending on February 8th, 2018. The claim was denied accordingly based on this information. If you disagree with the claim decision reached with your veterinarian’s notes, you are welcome to file an appeal with supporting documents. We see you have cancelled your policy and wish you and your pets the best.

Hi ***, we understand your concern for coverage. In order to accurately process claims, we request medical records from your veterinarian directly. Medical records indicate the claimed condition originated November 14th, 2017. However, the policy for Fran enrolled January 25th, 2018 with your medical waiting period ending on February 8th, 2018. The claim was denied accordingly based on this information. If you disagree with the claim decision reached with your veterinarian’s notes, you are welcome to file an appeal with supporting documents. We see you have cancelled your policy and wish you and your pets the best.

Hi ***, we understand your concern for coverage. In order to accurately process claims, we request medical records from your veterinarian directly. Medical records indicate the claimed condition originated November 14th, 2017. However, the policy for Fran enrolled January 25th, 2018 with your medical waiting period ending on February 8th, 2018. The claim was denied accordingly based on this information. If you disagree with the claim decision reached with your veterinarian’s notes, you are welcome to file an appeal with supporting documents. We see you have cancelled your policy and wish you and your pets the best.

Hi ***, we are sorry to hear you’ve had a negative experience and appreciate your feedback. Pre-existing conditions are not covered by any insurance company and in order to accurately process claims, we request medical records directly from your veterinarian. Per the medical records, the claimed conditions originated prior to the effective date of your policy. Therefore, denied accordingly. If you disagree with the claim decision, you are welcome to file an appeal with supporting documents by filling out the appeal form that was emailed to you by our claims representative. We are sorry to see you have cancelled your policy and wish you the best.

Hi ***, we are sorry to hear you’ve had a negative experience and appreciate your feedback. Pre-existing conditions are not covered by any insurance company and in order to accurately process claims, we request medical records directly from your veterinarian. Per the medical records, the claimed conditions originated prior to the effective date of your policy. Therefore, denied accordingly. If you disagree with the claim decision, you are welcome to file an appeal with supporting documents by filling out the appeal form that was emailed to you by our claims representative. We are sorry to see you have cancelled your policy and wish you the best.

Hi ***, we are sorry to hear you’ve had a negative experience and appreciate your feedback. Pre-existing conditions are not covered by any insurance company and in order to accurately process claims, we request medical records directly from your veterinarian. Per the medical records, the claimed conditions originated prior to the effective date of your policy. Therefore, denied accordingly. If you disagree with the claim decision, you are welcome to file an appeal with supporting documents by filling out the appeal form that was emailed to you by our claims representative. We are sorry to see you have cancelled your policy and wish you the best.

Hi ***, we are sorry to hear you’ve had a negative experience and appreciate your feedback. Pre-existing conditions are not covered by any insurance company and in order to accurately process claims, we request medical records directly from your veterinarian. Per the medical records, the claimed conditions originated prior to the effective date of your policy. Therefore, denied accordingly. If you disagree with the claim decision, you are welcome to file an appeal with supporting documents by filling out the appeal form that was emailed to you by our claims representative. We are sorry to see you have cancelled your policy and wish you the best.

Pets Best Pet Health Insurance Company (“Pets Best”) submits this response to *** complaint received on December 11, 2018. Pets Best is the marketer and administrator of policies underwritten by American Pet Insurance Company. Pets Best is a valid insurance agencycompany (NAIC #26581), duly licensed in all fifty states and Washington D.C. to sell pet health insurance plans.
The first section explains that Ms. claim was denied because her pet’s symptoms manifested before she purchased the policy and during the applicable waiting period. Entries from the medical records are included and support that finding. The second section addresses her claim of pre-approval. The third section provides a detailed account of the correct time-periods, dates, and interactions between Pets Best representatives with Ms. and her veterinarian.
I. Basis for Claim Denial
Unfortunately, Ms. pet was diagnosed with Nasopharyngeal Hyperplasia and the medical records from *** (unless otherwise noted) document symptoms pre-dating inception of the policy. Relevant entries from the records are as follows:
· 07/09/16: occ clear discharge OU, o keeps clean.
· 01/13/17: Doxycycline prescribed.
· 01/27/17 (Letter from DVM on 9/20/18): Pet prescribed Doxycycline for upper respiratory infection.
· 02/18/17: A history of tachypnea is documented:
o ABNORMALITIES: Respiratory increased upper airway sounds; no open mouth breathing while here; lungs clear;
o DIAGNOSES: Tachypnea;
o Noted to stop Doxycycline.
· 02/18/17 (*** Records):
o Presented with symptoms of increased respiratory noises (upper and lower airway);
o Two-week history of Doxycycline;
o Vomited, appeared distressed and breathing heavily.
· 07/08/17:
o ABNORMALITIES: Respiratory; increased upper resp stridor [noisy breathing]; lungs clear; no sneezing in room; v. mild clear discharge from nares (stenotic);
o ASSESSMENT: Sneezing;
o NOTES: per o – since been of doxy, the sneezing or snoring sound has gotten worse; treatment with Doxy;
o Upper respiratory panel returned negative.
· 06/14/18: P has a history of nasal problems and P will open mouth breathing due to restricted nasal passage:
o NOTES: breathing problems from so long [ago] can disturbed (sic) everything and everything could end up being a problem;
· 06/19/18:
o ABNORMALITIES: Significant URT noise. Worse with stress. Mild increased BV sounds.
o NOTES: Nasopharyngeal Stenosis; specialist recommended for treatment options.
· 07/05/18: Concerned about ongoing breathing difficulties. Stridor and mild stenosis of nares. Nasopharyngeal Hyperplasia diagnosed.
Nasopharyngeal diseases are complicated, difficult to diagnose, and often diagnosed initially as respiratory diseases due to their symptoms. Symptoms include difficult breathing, open-mouth breathing, discharge, sneezing, and other respiratory noises. Records are critically important because recurring symptoms or multiple instances of similar conditions may require further testing and diagnostics in order to identify the underlying cause.
Ms. purchased her pet policy on January 20, 2017. Medication for treatment of an undiagnosed upper respiratory condition was prescribed on January 13, 2017 (confirmed in the medical records). Another prescription may have been issued on January 27, 2017. Pursuant to the terms of her policy, conditions that display signs or symptom prior to expiration of the mandatory illness waiting period are excluded from coverage. The illness waiting period expired on February 3, 2017. Unfortunately, because Ms. pet had documented symptoms consistent with the diagnosed Nasopharyngeal Hyperplasia present prior to and during the illness waiting period, coverage is not available under the policy.
II. Pets Best did Not Pre-Approve or Confirm that Coverage
Ms. claim was not pre-approved nor was there any guarantee or promise that her pet’s condition and treatments would be covered. Our policies, guidance materials, and other communications repeatedly state that we will not guarantee coverage via phone call alone. Our representatives are trained, monitored, evaluated, and audited on this issue due to the volume of calls with similar inquiries.
Ms. called on 05/23/18 asking whether an elongated pallet surgery would be eligible for coverage. The representative first gave the standard disclaimer that coverage could not be guaranteed over the phone and then directed Ms. to the terms of her policy and the section discussing exclusions for conditions that have signs or symptoms prior to the policy or within any waiting period. Our customer service representatives do not make coverage decisions.
III. Detailed Timeline and Interactions
On 05/23/18, Ms. contacted customer service asking whether surgery for her pet’s condition would be covered under her policy. She was informed that determination could not be made until after the surgery occurred and was directed to the exclusions set forth in her policy.
On 06/30/18, she called to check on the status of a claim. However, no claim had been submitted.
On 07/13/18 Ms. again called regarding the status of her claim, but again, no claim had been submitted. The claim was uploaded later that day with limited medical records.
Pets Best requested records from *** on 07/17 & 07/18 and received limited records on 07/18. Upon receipt, a representative noted the records were incomplete and contacted Ms. to clarify the timeframe of the records she would need to provide.
On 07/25, Ms. stated that *** was the only provider that she had taken her pet to and that he had never been ill (notably inconsistent with the medical records).
Her claim was denied on 08/02/18 and an Explanation of Benefits was sent citing lack of medical records as the basis for denial.
On 08/03/18, Ms. called and was upset her claim was denied. She was informed that she would need to submit additional medical records. Additional records were received on 08/05/18 from ***.
Ms. inquired about her claim’s status on 08/09/18 and was advised medical records were being reviewed to determine if the claim could be reopened. On 008/14/18, she was informed that her claim would be re-opened and to allow 10 business days for processing.
The claim was again denied on 08/22/18 as the records from *** had still not been provided. A representative contacted Ms. on 08/22/18 to discuss the claim denial. Ms. advised it was not a good time to talk, so the representative said she would send the details in an email. Ms. stated she would contact Pets Best if she had any questions. The email stated:
We had closed a claim for Tyler due to lack of medical records. Some medical records were received from ***, however, based on the weight history and diagnosis summary, there should be exam notes from 2/18/17 and 7/8/17. The medical records for 7/8/17 are not necessarily needed, but we need the medical records for 2/18/17 to be able to continue to process your claim. You are welcome to obtain the medical records for 2/18/2017 from *** and send them to us. Once they are received, we will be able to re-open and continue to process your claim.
Ms. called shortly after this was received, angry that Pets Best had not contacted *** directly. The representative sought to appease Ms. and called the provider on Ms. behalf. However, they were closed and the representative left a detailed voicemail specifying exactly what was required. The representative called Ms. after to give her an update and inform her she would call again in the morning.
On 08/23/18, Ms. called to confirm medical records had been received. The representative confirmed that some had been provided, but *** did not include the exam/veterinarian notes (which had been specifically requested) for all the dates of service. The representative contacted the Christensen and had all the records emailed directly. *** confirmed the pet had been a patient since 2013 but that they only had exam/veterinarian notes dating back to 07/09/16.
Ms. called regarding her claim on 8/30/18 and was reminded that the review process was not immediate. She called again on 09/05/18 and informed that additional records were obtained on 08/27/18 and processing could take up to 14 days. The claims were denied on 9/8/18 as a pre-existing condition and an EOB was sent accordingly.
On 09/18/18, Ms. contacted customer service regarding denial and was again informed that her pet’s condition was documented in the medical records prior to 01/20/17—the date she purchased the policy. Ms. responded that she purchased the policy four years ago and asserting that the representative lied and deleted a previous policy (our system does not permit such actions). Ms. was provided an appeal form to appeal the denial.
The appeal was submitted on 09/21/18. She called on 10/04/18 requesting the previous representative by name and inquired about the status of her appeal. The representative informed her that, pursuant to her policy, appeals may take up to 30 days. This appeal was denied on 10/23/18 due to incomplete medical records (a denial for “Incomplete” allows for a First Level Appeal to be re-opened if additional medical records are submitted).
First Level Appeal was re-opened on 10/30/18 after records from *** dated 02/18/17 were provided. However, the appeal was denied on 12/03/18 as a pre-existing condition not eligible for coverage under the policy.
On 12/10/18, Ms. called regarding denial of her appeal and demanded to speak with the claims processor or management. The representative declined such request explaining neither could change the outcome of her appeal. Apparently, Ms. was not satisfied and attempted to contact Pets Best’s V.P. of Claims/ General Counsel. Ms. angrily stated she would be “disgracing Pets Best” with complaints to the Revdex.com and state Department of Insurance and disconnected the call.
Conclusion
Pets Best works diligently to provide the highest levels of satisfaction and customer service to our policy holders. While she complains of 56 apparent complaints, she omits that this would be in relations to the hundreds-of-thousands of claims processed this year alone. As Ms. points out, the Revdex.com has confirmed our commitment to providing excellent service with an A+ rating.

Despite receiving a closure letter from the Revdex.com on this matter after providing a very detailed explanation and timeline (attached again), Pets Best has been asked again to respond. Specifically, the Revdex.com has clarified that we should:
1. Address the consumers issue with the pre-existing diagnosis;
2. Contact with a claims adjuster- please give the consumer information to be able to do so.
As to the first issue, we are unclear what else could possibly be provided in response. The Pre-existing Condition issue is thoroughly explained in our original response and includes a detailed time-line of the symptoms documented in the medical records. The DVM’s letter explicitly states that the Doxycycline was prescribed to treat the pet’s upper respiratory infection just prior to inception of the policy. Again, this was clearly set forth in our original response. Ms. opinion otherwise is expressly contradicted by the medical records and her DVM’s statements. We note further that antibiotics have no impact on viruses—further discounting Ms. contentions on this matter.
Turning to the second issue, Pets Best does not have claims adjuster as there is nothing to adjust. We have claims processors who are tasked with analyzing medical records for objective evidence to process claims. They do not analyze the value of the claims or otherwise dictate how much a DVM can charge for certain procedures. Because the process turns on the objective evidence provided in the medical records and other documentation, there is no reason for our claims personnel to speak with policyholders. Our policy holders are free to submit additional information throughout this process and to speak with our customer service representatives.
Ms. continued attempts to dispute the contents of the medical records she provided is exactly why our customer service representatives do not transfer calls to the claims’ processors. Ms. statements do not change the contents of the medical records or her own DVM’s statement that her pet was diagnosed with and prescribed antibiotics for an upper-respiratory infection. Nor would a conversation with Ms. change the fact that antibiotics are useless against viral infections.
We stand by our decision to deny Ms. claims for reimbursement as her pet displayed signs or symptoms of the condition prior to inception of the policy.

***1 DOCUMENT REDACTED BY THE Revdex.com

Pets Best Pet Health Insurance Company (“Pets Best”) submits this response to *** complaint received on December 11, 2018. Pets Best is the marketer and administrator of policies underwritten by American Pet Insurance Company. Pets Best is a valid insurance agencycompany (NAIC #26581), duly licensed in all fifty states and Washington D.C. to sell pet health insurance plans.
The first section explains that Ms. claim was denied because her pet’s symptoms manifested before she purchased the policy and during the applicable waiting period. Entries from the medical records are included and support that finding. The second section addresses her claim of pre-approval. The third section provides a detailed account of the correct time-periods, dates, and interactions between Pets Best representatives with Ms. and her veterinarian.
I. Basis for Claim Denial
Unfortunately, Ms. pet was diagnosed with Nasopharyngeal Hyperplasia and the medical records from *** (unless otherwise noted) document symptoms pre-dating inception of the policy. Relevant entries from the records are as follows:
· 07/09/16: occ clear discharge OU, o keeps clean.
· 01/13/17: Doxycycline prescribed.
· 01/27/17 (Letter from DVM on 9/20/18): Pet prescribed Doxycycline for upper respiratory infection.
· 02/18/17: A history of tachypnea is documented:
o ABNORMALITIES: Respiratory increased upper airway sounds; no open mouth breathing while here; lungs clear;
o DIAGNOSES: Tachypnea;
o Noted to stop Doxycycline.
· 02/18/17 (*** Records):
o Presented with symptoms of increased respiratory noises (upper and lower airway);
o Two-week history of Doxycycline;
o Vomited, appeared distressed and breathing heavily.
· 07/08/17:
o ABNORMALITIES: Respiratory; increased upper resp stridor [noisy breathing]; lungs clear; no sneezing in room; v. mild clear discharge from nares (stenotic);
o ASSESSMENT: Sneezing;
o NOTES: per o – since been of doxy, the sneezing or snoring sound has gotten worse; treatment with Doxy;
o Upper respiratory panel returned negative.
· 06/14/18: P has a history of nasal problems and P will open mouth breathing due to restricted nasal passage:
o NOTES: breathing problems from so long [ago] can disturbed (sic) everything and everything could end up being a problem;
· 06/19/18:
o ABNORMALITIES: Significant URT noise. Worse with stress. Mild increased BV sounds.
o NOTES: Nasopharyngeal Stenosis; specialist recommended for treatment options.
· 07/05/18: Concerned about ongoing breathing difficulties. Stridor and mild stenosis of nares. Nasopharyngeal Hyperplasia diagnosed.
Nasopharyngeal diseases are complicated, difficult to diagnose, and often diagnosed initially as respiratory diseases due to their symptoms. Symptoms include difficult breathing, open-mouth breathing, discharge, sneezing, and other respiratory noises. Records are critically important because recurring symptoms or multiple instances of similar conditions may require further testing and diagnostics in order to identify the underlying cause.
Ms. purchased her pet policy on January 20, 2017. Medication for treatment of an undiagnosed upper respiratory condition was prescribed on January 13, 2017 (confirmed in the medical records). Another prescription may have been issued on January 27, 2017. Pursuant to the terms of her policy, conditions that display signs or symptom prior to expiration of the mandatory illness waiting period are excluded from coverage. The illness waiting period expired on February 3, 2017. Unfortunately, because Ms. pet had documented symptoms consistent with the diagnosed Nasopharyngeal Hyperplasia present prior to and during the illness waiting period, coverage is not available under the policy.
II. Pets Best did Not Pre-Approve or Confirm that Coverage
Ms. claim was not pre-approved nor was there any guarantee or promise that her pet’s condition and treatments would be covered. Our policies, guidance materials, and other communications repeatedly state that we will not guarantee coverage via phone call alone. Our representatives are trained, monitored, evaluated, and audited on this issue due to the volume of calls with similar inquiries.
Ms. called on 05/23/18 asking whether an elongated pallet surgery would be eligible for coverage. The representative first gave the standard disclaimer that coverage could not be guaranteed over the phone and then directed Ms. to the terms of her policy and the section discussing exclusions for conditions that have signs or symptoms prior to the policy or within any waiting period. Our customer service representatives do not make coverage decisions.
III. Detailed Timeline and Interactions
On 05/23/18, Ms. contacted customer service asking whether surgery for her pet’s condition would be covered under her policy. She was informed that determination could not be made until after the surgery occurred and was directed to the exclusions set forth in her policy.
On 06/30/18, she called to check on the status of a claim. However, no claim had been submitted.
On 07/13/18 Ms. again called regarding the status of her claim, but again, no claim had been submitted. The claim was uploaded later that day with limited medical records.
Pets Best requested records from *** on 07/17 & 07/18 and received limited records on 07/18. Upon receipt, a representative noted the records were incomplete and contacted Ms. to clarify the timeframe of the records she would need to provide.
On 07/25, Ms. stated that *** was the only provider that she had taken her pet to and that he had never been ill (notably inconsistent with the medical records).
Her claim was denied on 08/02/18 and an Explanation of Benefits was sent citing lack of medical records as the basis for denial.
On 08/03/18, Ms. called and was upset her claim was denied. She was informed that she would need to submit additional medical records. Additional records were received on 08/05/18 from ***.
Ms. inquired about her claim’s status on 08/09/18 and was advised medical records were being reviewed to determine if the claim could be reopened. On 008/14/18, she was informed that her claim would be re-opened and to allow 10 business days for processing.
The claim was again denied on 08/22/18 as the records from *** had still not been provided. A representative contacted Ms. on 08/22/18 to discuss the claim denial. Ms. advised it was not a good time to talk, so the representative said she would send the details in an email. Ms. stated she would contact Pets Best if she had any questions. The email stated:
We had closed a claim for Tyler due to lack of medical records. Some medical records were received from ***, however, based on the weight history and diagnosis summary, there should be exam notes from 2/18/17 and 7/8/17. The medical records for 7/8/17 are not necessarily needed, but we need the medical records for 2/18/17 to be able to continue to process your claim. You are welcome to obtain the medical records for 2/18/2017 from *** and send them to us. Once they are received, we will be able to re-open and continue to process your claim.
Ms. called shortly after this was received, angry that Pets Best had not contacted *** directly. The representative sought to appease Ms. and called the provider on Ms. behalf. However, they were closed and the representative left a detailed voicemail specifying exactly what was required. The representative called Ms. after to give her an update and inform her she would call again in the morning.
On 08/23/18, Ms. called to confirm medical records had been received. The representative confirmed that some had been provided, but *** did not include the exam/veterinarian notes (which had been specifically requested) for all the dates of service. The representative contacted the Christensen and had all the records emailed directly. *** confirmed the pet had been a patient since 2013 but that they only had exam/veterinarian notes dating back to 07/09/16.
Ms. called regarding her claim on 8/30/18 and was reminded that the review process was not immediate. She called again on 09/05/18 and informed that additional records were obtained on 08/27/18 and processing could take up to 14 days. The claims were denied on 9/8/18 as a pre-existing condition and an EOB was sent accordingly.
On 09/18/18, Ms. contacted customer service regarding denial and was again informed that her pet’s condition was documented in the medical records prior to 01/20/17—the date she purchased the policy. Ms. responded that she purchased the policy four years ago and asserting that the representative lied and deleted a previous policy (our system does not permit such actions). Ms. was provided an appeal form to appeal the denial.
The appeal was submitted on 09/21/18. She called on 10/04/18 requesting the previous representative by name and inquired about the status of her appeal. The representative informed her that, pursuant to her policy, appeals may take up to 30 days. This appeal was denied on 10/23/18 due to incomplete medical records (a denial for “Incomplete” allows for a First Level Appeal to be re-opened if additional medical records are submitted).
First Level Appeal was re-opened on 10/30/18 after records from *** dated 02/18/17 were provided. However, the appeal was denied on 12/03/18 as a pre-existing condition not eligible for coverage under the policy.
On 12/10/18, Ms. called regarding denial of her appeal and demanded to speak with the claims processor or management. The representative declined such request explaining neither could change the outcome of her appeal. Apparently, Ms. was not satisfied and attempted to contact Pets Best’s V.P. of Claims/ General Counsel. Ms. angrily stated she would be “disgracing Pets Best” with complaints to the Revdex.com and state Department of Insurance and disconnected the call.
Conclusion
Pets Best works diligently to provide the highest levels of satisfaction and customer service to our policy holders. While she complains of 56 apparent complaints, she omits that this would be in relations to the hundreds-of-thousands of claims processed this year alone. As Ms. points out, the Revdex.com has confirmed our commitment to providing excellent service with an A+ rating.

Despite receiving a closure letter from the Revdex.com on this matter after providing a very detailed explanation and timeline (attached again), Pets Best has been asked again to respond. Specifically, the Revdex.com has clarified that we should:
1. Address the consumers issue with the pre-existing diagnosis;
2. Contact with a claims adjuster- please give the consumer information to be able to do so.
As to the first issue, we are unclear what else could possibly be provided in response. The Pre-existing Condition issue is thoroughly explained in our original response and includes a detailed time-line of the symptoms documented in the medical records. The DVM’s letter explicitly states that the Doxycycline was prescribed to treat the pet’s upper respiratory infection just prior to inception of the policy. Again, this was clearly set forth in our original response. Ms. opinion otherwise is expressly contradicted by the medical records and her DVM’s statements. We note further that antibiotics have no impact on viruses—further discounting Ms. contentions on this matter.
Turning to the second issue, Pets Best does not have claims adjuster as there is nothing to adjust. We have claims processors who are tasked with analyzing medical records for objective evidence to process claims. They do not analyze the value of the claims or otherwise dictate how much a DVM can charge for certain procedures. Because the process turns on the objective evidence provided in the medical records and other documentation, there is no reason for our claims personnel to speak with policyholders. Our policy holders are free to submit additional information throughout this process and to speak with our customer service representatives.
Ms. continued attempts to dispute the contents of the medical records she provided is exactly why our customer service representatives do not transfer calls to the claims’ processors. Ms. statements do not change the contents of the medical records or her own DVM’s statement that her pet was diagnosed with and prescribed antibiotics for an upper-respiratory infection. Nor would a conversation with Ms. change the fact that antibiotics are useless against viral infections.
We stand by our decision to deny Ms. claims for reimbursement as her pet displayed signs or symptoms of the condition prior to inception of the policy.

***1 DOCUMENT REDACTED BY THE Revdex.com

Pets Best Pet Health Insurance Company (“Pets Best”) submits this response to *** complaint received on December 11, 2018. Pets Best is the marketer and administrator of policies underwritten by American Pet Insurance Company. Pets Best is a valid insurance agencycompany (NAIC #26581), duly licensed in all fifty states and Washington D.C. to sell pet health insurance plans.
The first section explains that Ms. claim was denied because her pet’s symptoms manifested before she purchased the policy and during the applicable waiting period. Entries from the medical records are included and support that finding. The second section addresses her claim of pre-approval. The third section provides a detailed account of the correct time-periods, dates, and interactions between Pets Best representatives with Ms. and her veterinarian.
I. Basis for Claim Denial
Unfortunately, Ms. pet was diagnosed with Nasopharyngeal Hyperplasia and the medical records from *** (unless otherwise noted) document symptoms pre-dating inception of the policy. Relevant entries from the records are as follows:
· 07/09/16: occ clear discharge OU, o keeps clean.
· 01/13/17: Doxycycline prescribed.
· 01/27/17 (Letter from DVM on 9/20/18): Pet prescribed Doxycycline for upper respiratory infection.
· 02/18/17: A history of tachypnea is documented:
o ABNORMALITIES: Respiratory increased upper airway sounds; no open mouth breathing while here; lungs clear;
o DIAGNOSES: Tachypnea;
o Noted to stop Doxycycline.
· 02/18/17 (*** Records):
o Presented with symptoms of increased respiratory noises (upper and lower airway);
o Two-week history of Doxycycline;
o Vomited, appeared distressed and breathing heavily.
· 07/08/17:
o ABNORMALITIES: Respiratory; increased upper resp stridor [noisy breathing]; lungs clear; no sneezing in room; v. mild clear discharge from nares (stenotic);
o ASSESSMENT: Sneezing;
o NOTES: per o – since been of doxy, the sneezing or snoring sound has gotten worse; treatment with Doxy;
o Upper respiratory panel returned negative.
· 06/14/18: P has a history of nasal problems and P will open mouth breathing due to restricted nasal passage:
o NOTES: breathing problems from so long [ago] can disturbed (sic) everything and everything could end up being a problem;
· 06/19/18:
o ABNORMALITIES: Significant URT noise. Worse with stress. Mild increased BV sounds.
o NOTES: Nasopharyngeal Stenosis; specialist recommended for treatment options.
· 07/05/18: Concerned about ongoing breathing difficulties. Stridor and mild stenosis of nares. Nasopharyngeal Hyperplasia diagnosed.
Nasopharyngeal diseases are complicated, difficult to diagnose, and often diagnosed initially as respiratory diseases due to their symptoms. Symptoms include difficult breathing, open-mouth breathing, discharge, sneezing, and other respiratory noises. Records are critically important because recurring symptoms or multiple instances of similar conditions may require further testing and diagnostics in order to identify the underlying cause.
Ms. purchased her pet policy on January 20, 2017. Medication for treatment of an undiagnosed upper respiratory condition was prescribed on January 13, 2017 (confirmed in the medical records). Another prescription may have been issued on January 27, 2017. Pursuant to the terms of her policy, conditions that display signs or symptom prior to expiration of the mandatory illness waiting period are excluded from coverage. The illness waiting period expired on February 3, 2017. Unfortunately, because Ms. pet had documented symptoms consistent with the diagnosed Nasopharyngeal Hyperplasia present prior to and during the illness waiting period, coverage is not available under the policy.
II. Pets Best did Not Pre-Approve or Confirm that Coverage
Ms. claim was not pre-approved nor was there any guarantee or promise that her pet’s condition and treatments would be covered. Our policies, guidance materials, and other communications repeatedly state that we will not guarantee coverage via phone call alone. Our representatives are trained, monitored, evaluated, and audited on this issue due to the volume of calls with similar inquiries.
Ms. called on 05/23/18 asking whether an elongated pallet surgery would be eligible for coverage. The representative first gave the standard disclaimer that coverage could not be guaranteed over the phone and then directed Ms. to the terms of her policy and the section discussing exclusions for conditions that have signs or symptoms prior to the policy or within any waiting period. Our customer service representatives do not make coverage decisions.
III. Detailed Timeline and Interactions
On 05/23/18, Ms. contacted customer service asking whether surgery for her pet’s condition would be covered under her policy. She was informed that determination could not be made until after the surgery occurred and was directed to the exclusions set forth in her policy.
On 06/30/18, she called to check on the status of a claim. However, no claim had been submitted.
On 07/13/18 Ms. again called regarding the status of her claim, but again, no claim had been submitted. The claim was uploaded later that day with limited medical records.
Pets Best requested records from *** on 07/17 & 07/18 and received limited records on 07/18. Upon receipt, a representative noted the records were incomplete and contacted Ms. to clarify the timeframe of the records she would need to provide.
On 07/25, Ms. stated that *** was the only provider that she had taken her pet to and that he had never been ill (notably inconsistent with the medical records).
Her claim was denied on 08/02/18 and an Explanation of Benefits was sent citing lack of medical records as the basis for denial.
On 08/03/18, Ms. called and was upset her claim was denied. She was informed that she would need to submit additional medical records. Additional records were received on 08/05/18 from ***.
Ms. inquired about her claim’s status on 08/09/18 and was advised medical records were being reviewed to determine if the claim could be reopened. On 008/14/18, she was informed that her claim would be re-opened and to allow 10 business days for processing.
The claim was again denied on 08/22/18 as the records from *** had still not been provided. A representative contacted Ms. on 08/22/18 to discuss the claim denial. Ms. advised it was not a good time to talk, so the representative said she would send the details in an email. Ms. stated she would contact Pets Best if she had any questions. The email stated:
We had closed a claim for Tyler due to lack of medical records. Some medical records were received from ***, however, based on the weight history and diagnosis summary, there should be exam notes from 2/18/17 and 7/8/17. The medical records for 7/8/17 are not necessarily needed, but we need the medical records for 2/18/17 to be able to continue to process your claim. You are welcome to obtain the medical records for 2/18/2017 from *** and send them to us. Once they are received, we will be able to re-open and continue to process your claim.
Ms. called shortly after this was received, angry that Pets Best had not contacted *** directly. The representative sought to appease Ms. and called the provider on Ms. behalf. However, they were closed and the representative left a detailed voicemail specifying exactly what was required. The representative called Ms. after to give her an update and inform her she would call again in the morning.
On 08/23/18, Ms. called to confirm medical records had been received. The representative confirmed that some had been provided, but *** did not include the exam/veterinarian notes (which had been specifically requested) for all the dates of service. The representative contacted the Christensen and had all the records emailed directly. *** confirmed the pet had been a patient since 2013 but that they only had exam/veterinarian notes dating back to 07/09/16.
Ms. called regarding her claim on 8/30/18 and was reminded that the review process was not immediate. She called again on 09/05/18 and informed that additional records were obtained on 08/27/18 and processing could take up to 14 days. The claims were denied on 9/8/18 as a pre-existing condition and an EOB was sent accordingly.
On 09/18/18, Ms. contacted customer service regarding denial and was again informed that her pet’s condition was documented in the medical records prior to 01/20/17—the date she purchased the policy. Ms. responded that she purchased the policy four years ago and asserting that the representative lied and deleted a previous policy (our system does not permit such actions). Ms. was provided an appeal form to appeal the denial.
The appeal was submitted on 09/21/18. She called on 10/04/18 requesting the previous representative by name and inquired about the status of her appeal. The representative informed her that, pursuant to her policy, appeals may take up to 30 days. This appeal was denied on 10/23/18 due to incomplete medical records (a denial for “Incomplete” allows for a First Level Appeal to be re-opened if additional medical records are submitted).
First Level Appeal was re-opened on 10/30/18 after records from *** dated 02/18/17 were provided. However, the appeal was denied on 12/03/18 as a pre-existing condition not eligible for coverage under the policy.
On 12/10/18, Ms. called regarding denial of her appeal and demanded to speak with the claims processor or management. The representative declined such request explaining neither could change the outcome of her appeal. Apparently, Ms. was not satisfied and attempted to contact Pets Best’s V.P. of Claims/ General Counsel. Ms. angrily stated she would be “disgracing Pets Best” with complaints to the Revdex.com and state Department of Insurance and disconnected the call.
Conclusion
Pets Best works diligently to provide the highest levels of satisfaction and customer service to our policy holders. While she complains of 56 apparent complaints, she omits that this would be in relations to the hundreds-of-thousands of claims processed this year alone. As Ms. points out, the Revdex.com has confirmed our commitment to providing excellent service with an A+ rating.

Despite receiving a closure letter from the Revdex.com on this matter after providing a very detailed explanation and timeline (attached again), Pets Best has been asked again to respond. Specifically, the Revdex.com has clarified that we should:
1. Address the consumers issue with the pre-existing diagnosis;
2. Contact with a claims adjuster- please give the consumer information to be able to do so.
As to the first issue, we are unclear what else could possibly be provided in response. The Pre-existing Condition issue is thoroughly explained in our original response and includes a detailed time-line of the symptoms documented in the medical records. The DVM’s letter explicitly states that the Doxycycline was prescribed to treat the pet’s upper respiratory infection just prior to inception of the policy. Again, this was clearly set forth in our original response. Ms. opinion otherwise is expressly contradicted by the medical records and her DVM’s statements. We note further that antibiotics have no impact on viruses—further discounting Ms. contentions on this matter.
Turning to the second issue, Pets Best does not have claims adjuster as there is nothing to adjust. We have claims processors who are tasked with analyzing medical records for objective evidence to process claims. They do not analyze the value of the claims or otherwise dictate how much a DVM can charge for certain procedures. Because the process turns on the objective evidence provided in the medical records and other documentation, there is no reason for our claims personnel to speak with policyholders. Our policy holders are free to submit additional information throughout this process and to speak with our customer service representatives.
Ms. continued attempts to dispute the contents of the medical records she provided is exactly why our customer service representatives do not transfer calls to the claims’ processors. Ms. statements do not change the contents of the medical records or her own DVM’s statement that her pet was diagnosed with and prescribed antibiotics for an upper-respiratory infection. Nor would a conversation with Ms. change the fact that antibiotics are useless against viral infections.
We stand by our decision to deny Ms. claims for reimbursement as her pet displayed signs or symptoms of the condition prior to inception of the policy.

***1 DOCUMENT REDACTED BY THE Revdex.com

Pets Best Pet Health Insurance Company (“Pets Best”) submits this response to *** complaint received on December 11, 2018. Pets Best is the marketer and administrator of policies underwritten by American Pet Insurance Company. Pets Best is a valid insurance agencycompany (NAIC #26581), duly licensed in all fifty states and Washington D.C. to sell pet health insurance plans.
The first section explains that Ms. claim was denied because her pet’s symptoms manifested before she purchased the policy and during the applicable waiting period. Entries from the medical records are included and support that finding. The second section addresses her claim of pre-approval. The third section provides a detailed account of the correct time-periods, dates, and interactions between Pets Best representatives with Ms. and her veterinarian.
I. Basis for Claim Denial
Unfortunately, Ms. pet was diagnosed with Nasopharyngeal Hyperplasia and the medical records from *** (unless otherwise noted) document symptoms pre-dating inception of the policy. Relevant entries from the records are as follows:
· 07/09/16: occ clear discharge OU, o keeps clean.
· 01/13/17: Doxycycline prescribed.
· 01/27/17 (Letter from DVM on 9/20/18): Pet prescribed Doxycycline for upper respiratory infection.
· 02/18/17: A history of tachypnea is documented:
o ABNORMALITIES: Respiratory increased upper airway sounds; no open mouth breathing while here; lungs clear;
o DIAGNOSES: Tachypnea;
o Noted to stop Doxycycline.
· 02/18/17 (*** Records):
o Presented with symptoms of increased respiratory noises (upper and lower airway);
o Two-week history of Doxycycline;
o Vomited, appeared distressed and breathing heavily.
· 07/08/17:
o ABNORMALITIES: Respiratory; increased upper resp stridor [noisy breathing]; lungs clear; no sneezing in room; v. mild clear discharge from nares (stenotic);
o ASSESSMENT: Sneezing;
o NOTES: per o – since been of doxy, the sneezing or snoring sound has gotten worse; treatment with Doxy;
o Upper respiratory panel returned negative.
· 06/14/18: P has a history of nasal problems and P will open mouth breathing due to restricted nasal passage:
o NOTES: breathing problems from so long [ago] can disturbed (sic) everything and everything could end up being a problem;
· 06/19/18:
o ABNORMALITIES: Significant URT noise. Worse with stress. Mild increased BV sounds.
o NOTES: Nasopharyngeal Stenosis; specialist recommended for treatment options.
· 07/05/18: Concerned about ongoing breathing difficulties. Stridor and mild stenosis of nares. Nasopharyngeal Hyperplasia diagnosed.
Nasopharyngeal diseases are complicated, difficult to diagnose, and often diagnosed initially as respiratory diseases due to their symptoms. Symptoms include difficult breathing, open-mouth breathing, discharge, sneezing, and other respiratory noises. Records are critically important because recurring symptoms or multiple instances of similar conditions may require further testing and diagnostics in order to identify the underlying cause.
Ms. purchased her pet policy on January 20, 2017. Medication for treatment of an undiagnosed upper respiratory condition was prescribed on January 13, 2017 (confirmed in the medical records). Another prescription may have been issued on January 27, 2017. Pursuant to the terms of her policy, conditions that display signs or symptom prior to expiration of the mandatory illness waiting period are excluded from coverage. The illness waiting period expired on February 3, 2017. Unfortunately, because Ms. pet had documented symptoms consistent with the diagnosed Nasopharyngeal Hyperplasia present prior to and during the illness waiting period, coverage is not available under the policy.
II. Pets Best did Not Pre-Approve or Confirm that Coverage
Ms. claim was not pre-approved nor was there any guarantee or promise that her pet’s condition and treatments would be covered. Our policies, guidance materials, and other communications repeatedly state that we will not guarantee coverage via phone call alone. Our representatives are trained, monitored, evaluated, and audited on this issue due to the volume of calls with similar inquiries.
Ms. called on 05/23/18 asking whether an elongated pallet surgery would be eligible for coverage. The representative first gave the standard disclaimer that coverage could not be guaranteed over the phone and then directed Ms. to the terms of her policy and the section discussing exclusions for conditions that have signs or symptoms prior to the policy or within any waiting period. Our customer service representatives do not make coverage decisions.
III. Detailed Timeline and Interactions
On 05/23/18, Ms. contacted customer service asking whether surgery for her pet’s condition would be covered under her policy. She was informed that determination could not be made until after the surgery occurred and was directed to the exclusions set forth in her policy.
On 06/30/18, she called to check on the status of a claim. However, no claim had been submitted.
On 07/13/18 Ms. again called regarding the status of her claim, but again, no claim had been submitted. The claim was uploaded later that day with limited medical records.
Pets Best requested records from *** on 07/17 & 07/18 and received limited records on 07/18. Upon receipt, a representative noted the records were incomplete and contacted Ms. to clarify the timeframe of the records she would need to provide.
On 07/25, Ms. stated that *** was the only provider that she had taken her pet to and that he had never been ill (notably inconsistent with the medical records).
Her claim was denied on 08/02/18 and an Explanation of Benefits was sent citing lack of medical records as the basis for denial.
On 08/03/18, Ms. called and was upset her claim was denied. She was informed that she would need to submit additional medical records. Additional records were received on 08/05/18 from ***.
Ms. inquired about her claim’s status on 08/09/18 and was advised medical records were being reviewed to determine if the claim could be reopened. On 008/14/18, she was informed that her claim would be re-opened and to allow 10 business days for processing.
The claim was again denied on 08/22/18 as the records from *** had still not been provided. A representative contacted Ms. on 08/22/18 to discuss the claim denial. Ms. advised it was not a good time to talk, so the representative said she would send the details in an email. Ms. stated she would contact Pets Best if she had any questions. The email stated:
We had closed a claim for Tyler due to lack of medical records. Some medical records were received from ***, however, based on the weight history and diagnosis summary, there should be exam notes from 2/18/17 and 7/8/17. The medical records for 7/8/17 are not necessarily needed, but we need the medical records for 2/18/17 to be able to continue to process your claim. You are welcome to obtain the medical records for 2/18/2017 from *** and send them to us. Once they are received, we will be able to re-open and continue to process your claim.
Ms. called shortly after this was received, angry that Pets Best had not contacted *** directly. The representative sought to appease Ms. and called the provider on Ms. behalf. However, they were closed and the representative left a detailed voicemail specifying exactly what was required. The representative called Ms. after to give her an update and inform her she would call again in the morning.
On 08/23/18, Ms. called to confirm medical records had been received. The representative confirmed that some had been provided, but *** did not include the exam/veterinarian notes (which had been specifically requested) for all the dates of service. The representative contacted the Christensen and had all the records emailed directly. *** confirmed the pet had been a patient since 2013 but that they only had exam/veterinarian notes dating back to 07/09/16.
Ms. called regarding her claim on 8/30/18 and was reminded that the review process was not immediate. She called again on 09/05/18 and informed that additional records were obtained on 08/27/18 and processing could take up to 14 days. The claims were denied on 9/8/18 as a pre-existing condition and an EOB was sent accordingly.
On 09/18/18, Ms. contacted customer service regarding denial and was again informed that her pet’s condition was documented in the medical records prior to 01/20/17—the date she purchased the policy. Ms. responded that she purchased the policy four years ago and asserting that the representative lied and deleted a previous policy (our system does not permit such actions). Ms. was provided an appeal form to appeal the denial.
The appeal was submitted on 09/21/18. She called on 10/04/18 requesting the previous representative by name and inquired about the status of her appeal. The representative informed her that, pursuant to her policy, appeals may take up to 30 days. This appeal was denied on 10/23/18 due to incomplete medical records (a denial for “Incomplete” allows for a First Level Appeal to be re-opened if additional medical records are submitted).
First Level Appeal was re-opened on 10/30/18 after records from *** dated 02/18/17 were provided. However, the appeal was denied on 12/03/18 as a pre-existing condition not eligible for coverage under the policy.
On 12/10/18, Ms. called regarding denial of her appeal and demanded to speak with the claims processor or management. The representative declined such request explaining neither could change the outcome of her appeal. Apparently, Ms. was not satisfied and attempted to contact Pets Best’s V.P. of Claims/ General Counsel. Ms. angrily stated she would be “disgracing Pets Best” with complaints to the Revdex.com and state Department of Insurance and disconnected the call.
Conclusion
Pets Best works diligently to provide the highest levels of satisfaction and customer service to our policy holders. While she complains of 56 apparent complaints, she omits that this would be in relations to the hundreds-of-thousands of claims processed this year alone. As Ms. points out, the Revdex.com has confirmed our commitment to providing excellent service with an A+ rating.

Despite receiving a closure letter from the Revdex.com on this matter after providing a very detailed explanation and timeline (attached again), Pets Best has been asked again to respond. Specifically, the Revdex.com has clarified that we should:
1. Address the consumers issue with the pre-existing diagnosis;
2. Contact with a claims adjuster- please give the consumer information to be able to do so.
As to the first issue, we are unclear what else could possibly be provided in response. The Pre-existing Condition issue is thoroughly explained in our original response and includes a detailed time-line of the symptoms documented in the medical records. The DVM’s letter explicitly states that the Doxycycline was prescribed to treat the pet’s upper respiratory infection just prior to inception of the policy. Again, this was clearly set forth in our original response. Ms. opinion otherwise is expressly contradicted by the medical records and her DVM’s statements. We note further that antibiotics have no impact on viruses—further discounting Ms. contentions on this matter.
Turning to the second issue, Pets Best does not have claims adjuster as there is nothing to adjust. We have claims processors who are tasked with analyzing medical records for objective evidence to process claims. They do not analyze the value of the claims or otherwise dictate how much a DVM can charge for certain procedures. Because the process turns on the objective evidence provided in the medical records and other documentation, there is no reason for our claims personnel to speak with policyholders. Our policy holders are free to submit additional information throughout this process and to speak with our customer service representatives.
Ms. continued attempts to dispute the contents of the medical records she provided is exactly why our customer service representatives do not transfer calls to the claims’ processors. Ms. statements do not change the contents of the medical records or her own DVM’s statement that her pet was diagnosed with and prescribed antibiotics for an upper-respiratory infection. Nor would a conversation with Ms. change the fact that antibiotics are useless against viral infections.
We stand by our decision to deny Ms. claims for reimbursement as her pet displayed signs or symptoms of the condition prior to inception of the policy.

***1 DOCUMENT REDACTED BY THE Revdex.com

8/24/2018 - Policy purchased online.

8/24/2018 – *** chatted to update pets weight and wellness coverage was added.

8/24/2018 – We called *** at *** and left message, confirming pet info added.

8/27/2018 – Rcvd Claim ***. Processed and paid on 8/28/2018. Wellness. $131.

8/27/2018 – Rcvd Claim *** processed and paid on 8/28/2018. Wellness. $88.

9/17/2018 – Underwriting review completed. No concerns.

9/19/2018 – Emailed *** with underwriting review info.

9/19/2018 – Rcvd Claim ***. Processed and applied to deductible on 9/24/2018.

9/24/2018 – Rcvd Claim ***. Processed and paid 9/27/2018. Wellness. $42.00

9/25/2018 – Payment failure notification

9/30/2018 – Successful payment email sent

10/25/2018, 10/30/2018 & 11/4/2018 – Payment failure notifications and non-pay warning

11/9/2018 – Successful payment email sent.

11/27/2018 – *** called to adv she had requested cancel at the end of August. Transferred to Supervisor. *** adv the request was September. Calls reviewed for that timeframe, could not locate any requests. Policy cx effective 11/28/2018.

I cannot find any other correspondence from the policyholder. All correspondence including calls and chats are attached.

The one numbers provided did not correspond with the alleged cancellation. Stated differently, there was never a call to cancel the Policy. Turning to the claim denials, there is an appeal process set forth in your policy you are free to engage in if you disagree with the determination of your claims. You can also find this information in your client portal.

8/24/2018 - Policy purchased online.

8/24/2018 – *** chatted to update pets weight and wellness coverage was added.

8/24/2018 – We called *** at *** and left message, confirming pet info added.

8/27/2018 – Rcvd Claim ***. Processed and paid on 8/28/2018. Wellness. $131.

8/27/2018 – Rcvd Claim *** processed and paid on 8/28/2018. Wellness. $88.

9/17/2018 – Underwriting review completed. No concerns.

9/19/2018 – Emailed *** with underwriting review info.

9/19/2018 – Rcvd Claim ***. Processed and applied to deductible on 9/24/2018.

9/24/2018 – Rcvd Claim ***. Processed and paid 9/27/2018. Wellness. $42.00

9/25/2018 – Payment failure notification

9/30/2018 – Successful payment email sent

10/25/2018, 10/30/2018 & 11/4/2018 – Payment failure notifications and non-pay warning

11/9/2018 – Successful payment email sent.

11/27/2018 – *** called to adv she had requested cancel at the end of August. Transferred to Supervisor. *** adv the request was September. Calls reviewed for that timeframe, could not locate any requests. Policy cx effective 11/28/2018.

I cannot find any other correspondence from the policyholder. All correspondence including calls and chats are attached.

The one numbers provided did not correspond with the alleged cancellation. Stated differently, there was never a call to cancel the Policy. Turning to the claim denials, there is an appeal process set forth in your policy you are free to engage in if you disagree with the determination of your claims. You can also find this information in your client portal.

8/24/2018 - Policy purchased online.

8/24/2018 – *** chatted to update pets weight and wellness coverage was added.

8/24/2018 – We called *** at *** and left message, confirming pet info added.

8/27/2018 – Rcvd Claim ***. Processed and paid on 8/28/2018. Wellness. $131.

8/27/2018 – Rcvd Claim *** processed and paid on 8/28/2018. Wellness. $88.

9/17/2018 – Underwriting review completed. No concerns.

9/19/2018 – Emailed *** with underwriting review info.

9/19/2018 – Rcvd Claim ***. Processed and applied to deductible on 9/24/2018.

9/24/2018 – Rcvd Claim ***. Processed and paid 9/27/2018. Wellness. $42.00

9/25/2018 – Payment failure notification

9/30/2018 – Successful payment email sent

10/25/2018, 10/30/2018 & 11/4/2018 – Payment failure notifications and non-pay warning

11/9/2018 – Successful payment email sent.

11/27/2018 – *** called to adv she had requested cancel at the end of August. Transferred to Supervisor. *** adv the request was September. Calls reviewed for that timeframe, could not locate any requests. Policy cx effective 11/28/2018.

I cannot find any other correspondence from the policyholder. All correspondence including calls and chats are attached.

The one numbers provided did not correspond with the alleged cancellation. Stated differently, there was never a call to cancel the Policy. Turning to the claim denials, there is an appeal process set forth in your policy you are free to engage in if you disagree with the determination of your claims. You can also find this information in your client portal.

8/24/2018 - Policy purchased online.

8/24/2018 – *** chatted to update pets weight and wellness coverage was added.

8/24/2018 – We called *** at *** and left message, confirming pet info added.

8/27/2018 – Rcvd Claim ***. Processed and paid on 8/28/2018. Wellness. $131.

8/27/2018 – Rcvd Claim *** processed and paid on 8/28/2018. Wellness. $88.

9/17/2018 – Underwriting review completed. No concerns.

9/19/2018 – Emailed *** with underwriting review info.

9/19/2018 – Rcvd Claim ***. Processed and applied to deductible on 9/24/2018.

9/24/2018 – Rcvd Claim ***. Processed and paid 9/27/2018. Wellness. $42.00

9/25/2018 – Payment failure notification

9/30/2018 – Successful payment email sent

10/25/2018, 10/30/2018 & 11/4/2018 – Payment failure notifications and non-pay warning

11/9/2018 – Successful payment email sent.

11/27/2018 – *** called to adv she had requested cancel at the end of August. Transferred to Supervisor. *** adv the request was September. Calls reviewed for that timeframe, could not locate any requests. Policy cx effective 11/28/2018.

I cannot find any other correspondence from the policyholder. All correspondence including calls and chats are attached.

The one numbers provided did not correspond with the alleged cancellation. Stated differently, there was never a call to cancel the Policy. Turning to the claim denials, there is an appeal process set forth in your policy you are free to engage in if you disagree with the determination of your claims. You can also find this information in your client portal.

Pets Best issues this response to ***’s complaint dated November 27, 2018. Mr. purchased an Accident and Illness pet health insurance policy effective on May 19, 2018. Mr. complains of being misinformed, delayed processing, and takes issue with his claims being denied due to a pre-existing condition.
As is standard with pet insurance, there are certain exclusions for pre-existing conditions and other related conditions. The application informs the applicant of these exceptions and asks if the pet has any pre-existing conditions. Mr.’s application did not disclose any pre-existing condition or symptoms.
Mr. submitted his claims to Pets Best on Saturday November 10 (#***, #***), Wednesday November 14 (#***), and Thursday November 15 (#***). His pet required a Femoral Head & Neck Ostectomy. The records submitted with the first claim stated “Bear is a 3 yr 8 mos nm DSH presented for painful RR. O feels may be another FHA surgery as one was done a few years back and he was told likely RR would need on[e] in future.” Due to the conflict between these records and Mr.’s application, additional records were required for review. Unfortunately, the subsequent records showed the pet suffered a broken hip, surgery with femoral head remodeling, and other treatment for related symptoms. Since the medical records documented the relation to the pet’s prior conditions, there was no basis for coverage under the policy.
On Monday, November 12 (the next business day), Pets Best sent a Request for Medical Records to *** Animal Hospital with Mr.’s information and requesting records from February 24, 2018 through November 10, 2018. The fax time-stamp at the top of this form confirms it was sent on November 12, 2018 at 10:08 A.M. Mountain time. Mr. inquired on November 13 as to the status of his claims and was informed we had yet to receive the records requested. Records obtained on November 15 were incomplete and did not span the time-period required. Notably, Mr. failed to disclose where he had taken his pet for the previous surgery until November 21. Complete records were not provided until November 25.
Complete records confirmed that Mr.’s pet had underwent a related previous surgery, had been informed that he would need additional surgery in the future, and received treatment for symptoms related to this condition at numerous points in between. Mr. appears to acknowledge this fact as noted in the medical records.
Pets Best provides excellent customer service at every step and did so with Mr.. All communications are recorded and time-stamped for reference and training purposes. A review of the communications with Mr. confirm he was never misinformed or mislead, he was never promised coverage or guarantees regarding the processing time and was informed at every step of the way what was needed and why. Further, when Mr. notified our representatives that he would be unable to pay his mortgage, we made every attempt to expedite, review, and process his claims. With Mr.’s consent, we will gladly provide records documenting this matter.
While it is unfortunate that Mr. was dissatisfied with what transpired, Pets Best went above and beyond what was required at every step of the way.
Cordially,

Jared H
General Counsel
Pets Best Pet Health Insurance Company
JH/no

Pets Best issues this response to ***’s complaint dated November 27, 2018. Mr. purchased an Accident and Illness pet health insurance policy effective on May 19, 2018. Mr. complains of being misinformed, delayed processing, and takes issue with his claims being denied due to a pre-existing condition.
As is standard with pet insurance, there are certain exclusions for pre-existing conditions and other related conditions. The application informs the applicant of these exceptions and asks if the pet has any pre-existing conditions. Mr.’s application did not disclose any pre-existing condition or symptoms.
Mr. submitted his claims to Pets Best on Saturday November 10 (#***, #***), Wednesday November 14 (#***), and Thursday November 15 (#***). His pet required a Femoral Head & Neck Ostectomy. The records submitted with the first claim stated “Bear is a 3 yr 8 mos nm DSH presented for painful RR. O feels may be another FHA surgery as one was done a few years back and he was told likely RR would need on[e] in future.” Due to the conflict between these records and Mr.’s application, additional records were required for review. Unfortunately, the subsequent records showed the pet suffered a broken hip, surgery with femoral head remodeling, and other treatment for related symptoms. Since the medical records documented the relation to the pet’s prior conditions, there was no basis for coverage under the policy.
On Monday, November 12 (the next business day), Pets Best sent a Request for Medical Records to *** Animal Hospital with Mr.’s information and requesting records from February 24, 2018 through November 10, 2018. The fax time-stamp at the top of this form confirms it was sent on November 12, 2018 at 10:08 A.M. Mountain time. Mr. inquired on November 13 as to the status of his claims and was informed we had yet to receive the records requested. Records obtained on November 15 were incomplete and did not span the time-period required. Notably, Mr. failed to disclose where he had taken his pet for the previous surgery until November 21. Complete records were not provided until November 25.
Complete records confirmed that Mr.’s pet had underwent a related previous surgery, had been informed that he would need additional surgery in the future, and received treatment for symptoms related to this condition at numerous points in between. Mr. appears to acknowledge this fact as noted in the medical records.
Pets Best provides excellent customer service at every step and did so with Mr.. All communications are recorded and time-stamped for reference and training purposes. A review of the communications with Mr. confirm he was never misinformed or mislead, he was never promised coverage or guarantees regarding the processing time and was informed at every step of the way what was needed and why. Further, when Mr. notified our representatives that he would be unable to pay his mortgage, we made every attempt to expedite, review, and process his claims. With Mr.’s consent, we will gladly provide records documenting this matter.
While it is unfortunate that Mr. was dissatisfied with what transpired, Pets Best went above and beyond what was required at every step of the way.
Cordially,

Jared H
General Counsel
Pets Best Pet Health Insurance Company
JH/no

Pets Best issues this response to ***’s complaint dated November 27, 2018. Mr. purchased an Accident and Illness pet health insurance policy effective on May 19, 2018. Mr. complains of being misinformed, delayed processing, and takes issue with his claims being denied due to a pre-existing condition.
As is standard with pet insurance, there are certain exclusions for pre-existing conditions and other related conditions. The application informs the applicant of these exceptions and asks if the pet has any pre-existing conditions. Mr.’s application did not disclose any pre-existing condition or symptoms.
Mr. submitted his claims to Pets Best on Saturday November 10 (#***, #***), Wednesday November 14 (#***), and Thursday November 15 (#***). His pet required a Femoral Head & Neck Ostectomy. The records submitted with the first claim stated “Bear is a 3 yr 8 mos nm DSH presented for painful RR. O feels may be another FHA surgery as one was done a few years back and he was told likely RR would need on[e] in future.” Due to the conflict between these records and Mr.’s application, additional records were required for review. Unfortunately, the subsequent records showed the pet suffered a broken hip, surgery with femoral head remodeling, and other treatment for related symptoms. Since the medical records documented the relation to the pet’s prior conditions, there was no basis for coverage under the policy.
On Monday, November 12 (the next business day), Pets Best sent a Request for Medical Records to *** Animal Hospital with Mr.’s information and requesting records from February 24, 2018 through November 10, 2018. The fax time-stamp at the top of this form confirms it was sent on November 12, 2018 at 10:08 A.M. Mountain time. Mr. inquired on November 13 as to the status of his claims and was informed we had yet to receive the records requested. Records obtained on November 15 were incomplete and did not span the time-period required. Notably, Mr. failed to disclose where he had taken his pet for the previous surgery until November 21. Complete records were not provided until November 25.
Complete records confirmed that Mr.’s pet had underwent a related previous surgery, had been informed that he would need additional surgery in the future, and received treatment for symptoms related to this condition at numerous points in between. Mr. appears to acknowledge this fact as noted in the medical records.
Pets Best provides excellent customer service at every step and did so with Mr.. All communications are recorded and time-stamped for reference and training purposes. A review of the communications with Mr. confirm he was never misinformed or mislead, he was never promised coverage or guarantees regarding the processing time and was informed at every step of the way what was needed and why. Further, when Mr. notified our representatives that he would be unable to pay his mortgage, we made every attempt to expedite, review, and process his claims. With Mr.’s consent, we will gladly provide records documenting this matter.
While it is unfortunate that Mr. was dissatisfied with what transpired, Pets Best went above and beyond what was required at every step of the way.
Cordially,

Jared H
General Counsel
Pets Best Pet Health Insurance Company
JH/no