S & W Machine LLC

Hello Revdex.com,The reason [redacted]'s recent claims for his pet [redacted] were not covered is because the condition is pre-existing. [redacted]'s policy started on 11/14/14, her 14 day illness waiting period ended on 11/28/14, and her six month orthopedic waiting period ended on 5/14/15. It was...

noted in the medical records on 11/15/14 that [redacted] had a mild positive drawer sign and mild laxity in her right knee under sedation. As a positive drawer sign is an indication of a cruciate ligament tear, and it was noted during her orthopedic waiting period, this condition is excluded from her policy. Additionally, cruciate ligament tears are a bilateral exclusion (as noted in the Embrace Terms and Conditions included below), so this condition is excluded in both her knees for the life of the policy. Unfortunately, because [redacted] was noted to have clinical signs (positive drawer sign) of a torn cruciate ligament during the six month waiting period, we were unable to cover the recent claims for a torn cruciate ligament. If you have any other questions, please feel free to contact me.Take care,Rachel H[redacted], RVTClaims, ManagerEmbrace Pet Insurance  From your Embrace terms and conditions document:PART I – DEFINITIONS5. Bilateral Condition is a condition or disease that affects both sides of the body. 8. Clinical Signs means changes in a Pet’s normal healthy state, bodily function or behavior observed by you, a Veterinarian, or other observer. 23. Orthopedic means the musculoskeletal system, which is made up of the body's bones (the skeleton), muscles, cartilage, tendons, ligaments, and joints.28. Pre-existing Condition(s) means:a. a Chronic Condition observed by you or your Veterinary Provider prior to the end of the Waiting Period for your Pet(s) and any related conditions; or b. an Illness or Injury that first occurred or showed Clinical Signs prior to the end of the Waiting Period for your Pet and any related conditions.Undiagnosed conditions with the same Clinical Signs as those in a. or b. above are also considered pre-existing.PART IV – EXCLUSIONS1. Pre-existing Conditions; In addition, the following Illness or Injury shall be considered Pre-existing Conditions:a. if your Pet has been diagnosed, prior to being insured, with a Bilateral Condition on one side of the body, she/he runs a higher risk of the same condition on the other side of the body and future occurrences of the same condition will not be covered. For example, but not limited to, if a dog has been diagnosed with a cruciate tear in his left leg before the end of the Waiting Period, a subsequent cruciate tear in his right leg shall be considered Pre-existing;

Our records show Mr. [redacted] cancelled his policy on 2/18/16. He received a pro-rated refund of $246.02. If he has not yet received these funds he should check with his bank. The refund was processed the same day.We also have not received any appeal letter or information to clarify the pre-policy dermatological issues from Mr. [redacted]'s veterinarians. We are unable to appeal the conditions without this information.We are unable to make exceptions in the policy terms and conditions due to the threat of not recommending us to adopters and kennel personnel. The policy terms and conditions are there to protect the company and the consumer. We stick to the policy, in this case and all others. While it is his right to express his opinion and displeasure, it's not something I want to happen, however, I cannot be expected to bend the rules or disregard the terms and conditions because he disagrees with what his veterinarian wrote in the pet's medical history.Please let me know if you have other concerns about this complaintjenna m[redacted], rvtclaims manager(800) 511-9172Embrace Pet Insurance

Please see attached document for response.

Hello Revdex.com, I am happy to provide more information about why we were unable to cover weight loss and giardia claims for [redacted] was diagnosed as underweight and giardia positive on 10/24/17, which was during the policy waiting period. This makes both conditions pre-existing...

and excluded from coverage. [redacted]’s illness waiting period was not complete until 11/2/17. The policy terms and conditions read as follows:       PART I – DEFINTIONS 26. Pre-existing Condition(s) means: a. a Chronic Condition observed by you or your Veterinary Provider prior to the end of the Waiting Period for your Pet(s) and any related conditions; or b. an Illness or Injury that first occurred or showed Clinical Signs prior to the end of the Waiting Period for your Pet and any related conditions. Undiagnosed conditions with the same Clinical Signs as those in (a) or (b) above are also considered pre-existing. 32. Waiting Period means the time period where the policy’s Coverage is restricted. For this policy, the time period is two (2) days for Injuries and fourteen (14) days for Illnesses, except for Orthopedic conditions for dogs where the Waiting Period is six (6) months.     PART III – COVERAGE                1. Coverage We will reimburse you for the cost of Treatment your Pet receives in the current period of insurance for an Illness or Injury that first showed Clinical Signs after the end of the Waiting Period.     PART IV – EXCLUSIONS               1. Pre-existing Conditions   This seems to be a clear case of a pre-existing condition. If [redacted] disagrees, he is welcome to submit additional information for an appeal of the issue. Please let me know if you need any additional information about this case.   Jenna M[redacted] Chief Underwriter and Claims Director Embrace Pet Insurance   Tell us why here...

[A default letter is provided here which indicates your acceptance of the business's response.  If you wish, you may update it before sending it.]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me. 
Regards,
[redacted]

Dear Revdex.com and Mr. [redacted],I cannot see how following our terms and conditions could be seen as unethical. We state this requirement in many places so our policy holders know there is a deadline. It would be unethical if we were trying to hide the deadline, but aren't trying to hide it, we are advertising it! Any company out there would do the same thing. We have to close our books of business from term to term with our underwriter, so we have to set a date for claims to be submitted by. This is the underwriter's rule and we have to follow it. Sometimes, as in this circumstance, it creates a bad experience for the policy holder, and while we would like to avoid this, the vast majority of claims are submitted within the required time frame.I looked at the claims in question and all of them would have been covered had they been submitted in a timely fashion. Please let me know if you have any questions.Jenna M[redacted], RVTClaims ManagerEmbrace Pet Insurance

[redacted] is absolutely correct - we thought we fixed the issue when he called us in June of 2016, and we were unaware that the double charge was still happening.  I am so sorry for that mistake on our part, and [redacted] will absolutely be refunded the $225.12 in over-payments.  He will see...

this credit on the payment type we have on file within about 2 business days.  Please give us a call at 800-511-9172 if you do not see this credit within the next two business days, or if there are any other issues we can help with.

Hello Revdex.com,I am unsure what Ms. [redacted] is referring to. We received the required evidence of pre-policy examination and the medical record on 1/13/17. The medical history and claims were put in line to be reviewed at that time. They came up for review on 2/2/17 and the claims...

were processed and covered on 2/3/17. Sometimes it takes a bit longer to receive all of the medical history we need in order to process a claim, perhaps this is what Ms. [redacted] is referring to. We are beholden to the veterinary clinics to provide us with their detailed medical records. We cannot help how long it takes for them to send it. Regardless, the claims are covered and Ms. [redacted] has received payment on them.Please let me know if there are any further questions about this case. Jenna M[redacted], RVTClaims ManagerEmbrace Pet Insurance

Dear Revdex.com, I am happy to explain the issue [redacted] is describing. [redacted]’s policy went into failed billing when the payment was due on 5/13/17. This means her account info had changed or there was not enough funds in the account to cover the charge. The amount she owed on 5/13/17 was $47.92 for...

her insurance policy and $46.95 for her Wellness Rewards program. Totaling $94.87. When [redacted] called us to update her billing on 6/2/17, we collected the overdue payment of $94.87. At this time she decided to drop her Wellness Rewards coverage. The Wellness Rewards coverage was dropped as of 6/2/17, therefore, she was due a pro-rated refund for the unused part of the month from 6/3/17 to 6/12/17 when her next payment would have been due; however, she had already been paid more out of the Wellness Rewards program than she had paid into it. In cases like these there is no refund due for a midterm cancellation. The Wellness Rewards program is meant to be kept for a full 12 months. If the policy holder cancels it early, they are not entitled to a ‘reward’. The program works by paying a monthly fee for a certain amount of wellness coverage. The amount of coverage you get is more than you pay into it. That extra amount is the ‘reward’, but as I stated, [redacted] had already been reimbursed more than she had paid into the program by over $60, so we could not give her any refund for the 9 days of that month that she did not have the wellness program. While the payments and refund are appropriate for this case, the communication on this complicated issue was not up to the Embrace standard and has been reviewed by the department manager. Due to the confusion [redacted] was given a supplemental payment of $25. The department of insurance regulates these types of payments and the limit is $25. Additionally, changes were made to the protocol for future communications in this type of situation so this does not happen in the future. I understand this outcome is not what [redacted] was hoping for with this Revdex.com complaint, but I hope this additional explanation helps her understand what happened and what steps were taken afterwards. Please let me know if you have any further questions. Respectfully, Jenna M[redacted], RVT Claims Manager Embrace Pet insurance Tell us why here...

I personally uploaded the actual claim forms TWICE WHICH CLEARLY state the medical diagnosis. They ignored the claim forms and both times and just put the claim on hold claiming they didn't have the information needed.
[redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
To say all of our claims would have been paid if filed timely is insulting and wrong. This company will find any excuse to deny or delay claims or otherwise confuse their paying customers so that claims are never paid. I have attached a document with a sampling of the correspondence we have received from Embrace. Each time they require further, burdensome information that is not necessary or find an excuse why the claim cannot be paid. They cannot deny they are unethical.
Regards,
*** ***

My response to this complaint was sent directly to [redacted] email on 12/20/17. The response is as follows:[redacted] I am happy to respond to Ms. [redacted]’s complaints. 1.      Any terminology used on the website or other documentation is defined in the policy terms and conditions. This is done for clarity and to avoid policyholder confusion with other policies and colloquial meanings. Pre-existing condition and waiting period are defined as follows:  Part I - Definitions26. Pre-existing Condition(s) means: a. a Chronic Condition observed by you or your Veterinary Provider prior to the end of the Waiting Period for your Pet(s) and any related conditions; or b. an Illness or Injury that first occurred or showed Clinical Signs prior to the end of the Waiting Period for your Pet and any related conditions. Undiagnosed conditions with the same Clinical Signs as those in (a) or (b) above are also considered pre-existing. 32. Waiting Period means the time period where the policy’s Coverage is restricted. For this policy, the time period is two (2) days for Injuries and fourteen (14) days for Illnesses, except for Orthopedic conditions for dogs where the Waiting Period is six (6) months. The Waiting Period starts from the Pet Original Start Date. Conditions that occur during the Waiting Period will be excluded from your policy’s Coverage as Pre-existing Conditions. The Waiting Period also applies to Coverage increases but is waived for policy renewals and Optional Coverage renewals. Part IV – Exclusions1. Pre-existing Conditions; In [redacted] case, he had been diagnosed with feline asthma in February of 2016, if not earlier. [redacted] policy began on 10/26/16. Since asthma is a chronic condition, which began before the policy start, it is a pre-existing condition as defined by the policy. Some non-chronic conditions that occur before the policy start can be covered if they are clear for a full 12 months. Asthma is not a curable condition.   Additionally, Embrace provides the option for a policy holder to request a medical history review to inform them of any pre-existing conditions to make sure they are comfortable with their coverage. If they are not comfortable, they have the ability to cancel the policy in the first 30 days for a full refund. Ms. Knusdson did not request a review at any point.   2.      The policy terms and conditions inform policy holders the policy auto-renews. This information is also on the website, and in our standard phone call acknowledgements read to each policy purchaser if they begin on the phone. 3.      I’m not actually sure what Ms. [redacted] is saying here, but since she cancelled her policy at the 12 month renewal, all she was able to be refunded for was the unused part of the renewed policy. She received a full refund for the second policy term. A policyholder is able to send in claims within 60 days or a policy cancellation or renewal. On 12/6/17 Ms. [redacted] submitted claims for January 2017 through September 2017. The claim was accepted, but was not covered because it was all for feline asthma.  Most complaints we receive on yelp, Revdex.com, and other places are from people who do not understand pre-existing conditions. We do try to educate the policyholders on these subjects as much as we can.  I hope this explanation helps Ms. [redacted] understand what occurred with her policy and please let me know if there are any additional questions.                                   ...⇄ />
 
 
[redacted]

Darcy L[redacted] <[email protected]>2:41 PM to me Dear [redacted], Here is Embrace Pet Insurance’s response to complaint #[redacted]: Embrace automatically renews policies each year, and we let Pet Parents know by sending them an e-mail about their upcoming renewal 60-90 days...

before the renewal date.  We sent these e-mails to Mr. [redacted] at the e-mail address he entered when he purchased the policy online:  [email protected] .   If this was not the correct address, we were never informed by Mr. [redacted], and we were never provided with an alternate address.  The e-mails were sent on the following dates:  11/26/13, 11/26/14, and 11/23/15.  We also follow up on the day of the renewal each year with an e-mail that includes the updated policy documents.  This e-mail was sent to Mr. [redacted] on 12/30 of each year that he held a policy.  Below is a copy of the renewal e-mail that is sent: Hello [redacted],I hope everything is going well. I am writing to let you know that your Embrace Pet Insurance will automatically renew on 12/31/2013. Annual premium for the new policy term will be $?330.54. Learn more about premium changes at renewal.I've attached a summary of your coverage, so please take a moment to review. Please review the terms and conditions. There have been no changes to the terms this year.The Healthy Pet Deductible (not available in WA) is now in place! If your pets do not exceed their annual accident and illness deductible during this policy term, you will receive an automatic $50 reduction in their deductible for the next policy term.If we do not hear from you, we will automatically renew your policy on 12/31/2013 using the payment method on file. If you need to update your billing information, please give us a call at 800-511-9172, M-F 8:30am-8pm Sat 9am-1pm ET. We appreciate your continued business, and look forward to continuing to “Embrace” you and your pet. Please don’t hesitate to let us know if you have any further questions or concerns about the renewal. Warm regards,Embrace Customer Care Team EmbracePetInsurance.comConnect with us on Facebook & Twitter Additionally, by signing up with a policy a policy holder agrees to electronic delivery of policy documents including the automatic renewal notices. The following is the pertinent excerpt from the terms and conditions: PART VII - OTHER TERMS AND CONDITIONS16. Electronic Delivery By accepting the terms of this insurance as evidenced by the payment of premiums, you agree that this policy, any endorsements and any notices shall be delivered to you by electronic mail via the Internet. We also define our cancellation reimbursement policy in our terms and conditions:  PART VII - OTHER TERMS AND CONDITIONS3. Cancellation Refund Upon cancellation, you may be entitled to a premium refund. If you provide us written notice of cancellation within thirty (30) days of the Original Start Date and you have made no Claim, we will refund the premium you paid us and the policy will be canceled. If you have made a Claim within thirty (30) days of the effective date, the premiums paid for or allocable to the first month of Coverage become fully earned upon the submittal of the Claim, and you will only receive a refund for any premiums paid for periods beyond the first month. After the first thirty (30) days of the policy period, we will compute any refund due on a daily pro-rata basis. Since Mr. [redacted] had active coverage from 12/31/12 to 2/2/16, we would not be able to issue a full refund as it is past the 30 day  money back guarantee.   We have done everything in good faith and according to our policy terms and conditions. Mr. [redacted] was provided a copy of the terms and conditions at the start of the policy and at every renewal. Please feel free to contact me with any further questions, darcy l[redacted]contact center manager(800) 511-9172 x133

I will always reject their response.The Company has a long history of denying claims citing "pre-existing conditions".Myself and hundreds of other pet owners have been scammed.If one reads their entire policy, they cover Nothing!
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
Regards,
[redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
[This consumer response was received by Revdex.com via email and is a copy/paste by [redacted]-I had previously filed the complaint. Embrace's response does not address the fact that my email exchange and conversation with Embrace led me to believe the policy covered my pet's preexisting conditions.   I recognize that their fine print states the terms, but my complaint is that I relied on their reps telling me the truth in advance of my decision to get insurance.  Also, the company reinforces customer misunderstanding by using  terms like "waiting period" in ways very different than is commonly understood in our own personal health coverage.  There is no way I would have purchased insurance had the rep been honest in answering my questions when I called in advance of my decision.  I provided them the email to show the lack of integrity.I request two things:A refund of my premiums.  I provided them the email exchange that clearly shows I was misled.Embrace to clarify its website that the waiting period is not for pre-existing conditions.[redacted]

Dear Revdex.com,I absolutely reject the business's response on this matter; however, I do appreciate your assistance in mediating.I will forward them a copy of a letter from my vet which clarifies that the dog in question has no "dermatological condition".  Additionally, I have absolutely not received any sort of a refund, pro rata or otherwise from this company.Furthermore, I'll note for the record that my girlfriend and I volunteer on the weekends for a dog shelter with about 110 dogs in their care on premises and about another 30 fostered at various volunteer residences whilst waiting for their forever home.  I will be making it my mission to share with any volunteer, pet owner, or potential pet adopter (whom I work with frequently) my extremely negative experience with Embrace.  I will recommend that anybody seeking fair treatment steer very clear of Embrace.Thanks again for your assistance in this matter and have a great weekend,[redacted]

Dear Revdex.com, I attached a copy of the fax we received from [redacted] on July 6, 2017. The fax contains a cover sheet and two invoices, but does not have a claim form for either invoice. We set up [redacted]’s claims based on the two invoices we received, but the claims were held up...

until we could obtain a diagnosis from [redacted]. We let [redacted] know on 7/7/17, 8/18/17, and 8/31/17 that we still had not received claim forms for either of the invoices we received, and that we were still missing the diagnosis for these visits. We verified the diagnosis today and processed both his pending claims. In the future, to insure minimal claims processing time, we need a claim form (filled out by the vet) and an invoice for each claim that [redacted] submits. This will allow us to get the claim set up and processed in the shortest amount of time. Please feel free to contact me with any other questions or concerns. Take care,     Rachel H[redacted], RVT Manager, Claims (800) 511-9172 EmbracePetInsurance.com

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
Embrace customer service was notified about the appointment I had for [redacted] for her medical review. I told a representative via email, so that records could be reviewed, see attached copy. The response from Embrace (to Revdex.com) states, "we did not know about The [redacted] Hospital." This is not true, as the address is on the invoice- embrace paid for -- dated 8/2014. Embrace had the address at that time & was told via my email about the appointment. I did not send an illness claim; I sent an invoice for a medication refill- given on the 8/2014 exam. Again, I would not have paid 7 months of coverage (which I have not used ) dated 9/2014-3/2015 --had I known Embrace considered [redacted] to have pre-existing conditions. I want my money reimbursed for these months.Attached photo is a copy of where I notified Embrace about my Dog's visit. Again, the invoice was sent with [redacted] vca's address (so you could have requested records & notified me of "pre existing" before I paid the 7 months. My pic I am attaching is in response to an Embrace representative asking for medical history. 
Regards,
[redacted]

Dear Revdex.com Representative,
I am happy to try and clarify our procedures for you and for
Ms. [redacted].
On 7/28/15 Ms. [redacted] let us know [redacted] had been seen by
VCA [redacted] in the past. We requested records from VCA [redacted] on 8/20/14
which was a few days after the 14 day policy waiting...

period. This is our
standard procedure so we make sure we get all of the needed notes with one
request instead of having to go back and request them again in case a pet had
an exam during the 14 day waiting period.
We received records for a date range of 5/2/12 through
8/11/14, though the last exam was done on 5/2/12. Since there was no exam in
the 12 months before the policy start these records did not fufill the exam
requirement. Ms. [redacted] knew [redacted] needed an exam and it was done at a
different hospital. VCA [redacted] Animal Hospital did the exam on 8/12/14. A
claim for that wellness exam was submitted and we covered it in full under her
wellness policy. We did not request the records from [redacted] at that
time. Usually, unless we know at the very start of the policy which vets have
examined a pet we do not request medical history until before the first illness
claim. We did not know about [redacted] at the very start of the policy.
Alternatively, we may request all of the records, if and
only if, the pet parent requests a medical history review for their pet. This
can be requested at any time and is a service we do free of charge. The pet
parents are informed of the availability of this service upon signing up for
the policy. This is the only time we will request all records and review them
before an illness claim has been submitted. We simply cannot review all records
we receive at the time we receive them. We do it only when we need to.
Sometimes we never need to review or request the records if we do not get
claims for a certain amount of time. Additionally, when we do receive records,
we send pet parents an email letting them know records came in and we would be
putting them on file in anticipation of any claims. At no time do we imply we
will be reviewing the records at the time of receipt unless a history review
has been requested. I do not see any record Ms. [redacted] requested a medical
history review, so we did not look at the records.
When the first illness claim for her pet, [redacted], came in
we requested, received, and reviewed the notes from VCA [redacted]. At that
time we became aware of several conditions that would be excluded from coverage
and we pre-emptively sent a medical history review email (even though it was
not requested) since we wanted Ms. [redacted] to be informed of what would not be
covered and for how long it would not be covered.
The policy states any issues noted in the 12 months before
the policy start (or on the first exam after the policy starts if there are no
exams in the pet’s 12 month past, such as in this case) they will be
pre-existing conditions and cannot be covered by the policy. The issues Ms.
[redacted] is stating are not pre-existing are things that were noted on that first
exam on 8/12/14. This makes them pre-existing conditions.
I am unable to acquiesce to Ms. [redacted]’s request for a full
refund as her pet was (and still is) covered under the insurance for any
non-pre-existing illnesses or accidents. A pet parent is able to cancel the policy
at any time, and Ms. [redacted] can do this by calling into our customer care
center. We will be able to offer a prorated refund for the month, as we would for
any policy holder.
Please feel free to contact me with any further questions or
concerns on this complaint.[redacted]claims managerEmbrace Pet Insurance(800) 511-9172

Bear Revdex.com,I am happy to explain Embrace Pet Insurance’s decision to
not cover this mass claim. Our policy terms and conditions specify any
undiagnosed mass present before the start of the policy will create an
exclusion of coverage for all other masses. The following is an excerpt for the
policy:...

    Part
IV - Exclusions:     e. If a Pet has been treated for undiagnosed masses prior to the end of the Waiting
Period, any mass, or condition where a mass is
a Clinical Sign,
is not covered, including     those caused by cancer. If the cause of the mass that
occurred prior to the end of the Waiting
Period can be diagnostically narrowed down via
cytology, un-related conditions     may be covered.The situation is this case is the same as what is stated in this
policy exclusion. There was a mass noted before the start of the policy. It was
never tested or definitely diagnosed, therefore according to the policy, no
other masses can be covered. Ms. [redacted] can
certainly appeal the outcome of this claim, but we would need more definitive
information to do so. Her veterinarian saying it is a “harmless mass” is not
enough information. An actual diagnosis, as the policy states (via cytology)
such as sebaceous cyst, lipoma, or mast cell tumor would be needed to narrow
down the exclusion and see if it is related to the current issue. Without this
diagnosis we are unable to cover the claim. If further information
is needed by the Revdex.com or Ms. [redacted], I would be happy to help.[redacted],Claims Manager,Embrace Pet Insurance