Pet insurance company denial based on pre-existing vomiting condition

[FlorasDad]

We had to say goodbye to our beloved Flora last weekend....She was diagnosed with small cell lypmpha last year and in the past month it became high grade and very aggressive. I am in the middle of sorting out her affairs, including her final vet bills and the pet insurance company is giving me a hard time.

I purchased pet insurance for Flora around the time she was having elevated liver/dental issues, the policy was effective April 21, 2022. I did this as a sort of wake up call, just in case she had other issues down the line, with the understanding that liver conditions and dental issues would not be covered.

She had the dental, made a full recovery and her liver values were normal for the rest of her life. However, several months after her dental, we noticed that she was losing a lot of weight despite normal appetite and vomiting frequently. We went through many tests including multiple ultrasounds and an endoscopy to finally diagnose that she unfortunately had small cell lymphoma. We started treatment, she gained her weight back, and we seemed to have a good control of the disease for several months.

The whole time, these procedures, bloodwork, rechecks etc. were all covered and paid out by her insurance. It wasn't until our policy renewed in April 2023 with no lapse in coverage, when I submitted a claim for a routine blood recheck with her oncologist, it was denied citing that because it was mentioned in her vet records that she "vomited occasionally" which was dated prior to the effective policy date which means that any related illnesses (her cancer) were considered pre-existing. I can't deny that it does mention vomits occasionally in her vet notes (what cat doesn't...), however this was pertaining to vomiting once in a while and accompanied with hairballs! At the time I appealed the decision (which was reviewed internally.... go figure...) and the denial stood. I wasn't able to escalate it further, and I let it go at the time because after the deductible, it would only be $100 or so and I figured it wasn't worth the extra stress. I just recently submitted to insurance a bill of her recent emergency visit because Flora was very sick and wasn't eating. During this visit, blood was drawn and an ultrasound was performed which showed that her cancer had become high grade...This claim was denied for the same reason as the previous one.

I feel that they are misconstruing the vet notes as a means to deny the claim... I'm sure it's a tale as old as time and I doubt my experience is unique. Seems that insurance companies love to use vomiting as a means to deny claims. I am in the middle of arguing with them that the vomiting that they claim is pre-existing is unrelated to her cancer. I have not pointed out to them the fact that they have approved and paid out previous claims pertaining to Flora's vomiting/diagnosis of lymphoma...meaning that they did not view it as pre-existing! I only hesitate because I don't know if they can come back and say "you're right" and ask for the money they paid out back. If they did that, that would be pretty sketchy and to me they should not be in business. That would mean they could approve claims, and then go back and ask for the money back if they change their mind.

It is unfortunate that I have to deal with this while grieving over the loss of our beloved family member...Any advice, commiseration, support would be greatly appreciated. Thank you in advance.

 

[carrie640]

I have no advice on this but this kind of thing happened to me about 20 years ago. I had bronchitis maybe 5 years prior to the health policy. A short time after I was eligible for coverage with an employer, I developed some other virus (can't recall what it was now) but it was NOT bronchitis. It was denied. All of it as pre-existing. It did not matter my pcp (primary care phy.) personally sent them a letter. That's what they said and they weren't paying. I was sick for three weeks and made numerous trips back to my PCP. No payment. These companies will find any thing to try and nail a diagnosis to a previous condition. It's disgusting. I'm so sorry you are going through this and I'm so sorry for the loss of your cat

 

[FlorasDad]

Thank you. Flora was a very sweet and special cat and was loved by all. We are going to miss her dearly.

I am so sorry you had to experience that…I am appalled that they would do that for human health insurance. No one should have to go through that when trying to take care of their own health.

 

[carrie640]

If you are in the US, then you are already aware that Obama ruled that there be no more pre-existing clauses in policies. The bad news is, huge rate hikes. EXTREMELY high. What most people don't understand is that pre-existing conditions were not law of the land. They were options for employers and individuals to keep premiums low. My employer at the time opted for it. It was the first and only employer that did it. I could have refused coverage from them and take out my own private policy. But, now we have people who can't have any because they can't afford the premiums (cost) and the enormous deductibles. But, either way, for a company to call something a pre-existing condition when it can be tied to ANYTHING (you can vomit from food poisoning. You can vomit from pregnancy, for example) is completely unacceptable. That's just really, really, bad and proves all they want is your money and don't give two sh*** about your poor cat We thought about taking out a policy for the other two (who have no history of conditions), but do you think it's worth it?

 

[fionasmom]

All five of my cats have insurance, and I will be back a little bit later today to try to add a little more to this if I feel that I can in anyway be helpful.

if you are in the United States, pet health insurance does have to answer to your state insurance board or whichever body governs insurance in your state. You can file a complaint or open a case with them. I threatened to do this once over a pet insurance claim in which the company insisted repeatedly that they had not received an extremely important piece of diagnostic information. I never actually had to do this though, because when I told him that they had five days to figure this out, or I would hit “submit”on the complaint they somehow saw their way through it.

I understand that you are concerned about being asked for reimbursement on what they might call an incorrectly submitted or falsified claim.

I am very sorry for your loss of Flora.

 

[FlorasDad]

If you are in the US, then you are already aware that Obama ruled that there be no more pre-existing clauses in policies. The bad news is, huge rate hikes. EXTREMELY high. What most people don't understand is that pre-existing conditions were not law of the land. They were options for employers and individuals to keep premiums low. My employer at the time opted for it. It was the first and only employer that did it. I could have refused coverage from them and take out my own private policy. But, now we have people who can't have any because they can't afford the premiums (cost) and the enormous deductibles. But, either way, for a company to call something a pre-existing condition when it can be tied to ANYTHING (you can vomit from food poisoning. You can vomit from pregnancy, for example) is completely unacceptable. That's just really, really, bad and proves all they want is your money and don't give two sh*** about your poor cat We thought about taking out a policy for the other two (who have no history of conditions), but do you think it's worth it?

Yup, in the US. I started working in 2018, prior I was on my dad's insurance (postal service) so I don't think I ever had to deal with the pre-existing clauses fortunately. I suppose getting rid of pre-existing clauses was a step forward, but it doesn't necessarily address the problem...it's really frustrating as a whole, the worst thing you can do is get sick in this country....

In terms of if pet insurance is worth it...even though I have mixed feelings about this topic due to this negative experience, but overall I still do think it is worth it, for emergencies/peace of mind.

I had pet insurance with a different company in 2018 for the first year I had Flora. After the first year, I debated on keeping the policy or not. The general consensus on pet insurance online is pretty negative, since it is not very regulated and many deal with claim denials for every reason under the sun. What many would suggest is essentially to fund a pet emergency/medical fund and use that which is not a bad idea. That is the route that I chose after the first year having Flora where she was healthy and had no claims. I do regret this decision to cancel looking back...I should have kept it to have no lapse in coverage even if for peace of mind. The cost at the time was about $20 a month for essentially an emergency only policy, which I can't believe I cancelled over...

Anyway...the bet did pay off as Flora was healthy and happy with us until her dental issues I mentioned above in 2022. Knowing full well that she was 5 years older than when she was last insured and that I may have to deal with insurance companies denying her claims based off previous medical history, I still decided that I would purchase a policy for her just in case of emergencies with the current company for roughly $30 a month.

A couple of months after the policy was in effect we noticed that she was losing a lot of weight and vomiting more frequently so we went down the path which ultimately lead to her diagnosis. I was skeptical as to whether the insurance would actually pay out, but they did with no fuss other than taking some time to pay out. It was a great relief that I could focus on treating my cat for her lymphoma without having to worry as much about the financial costs and for that, I am grateful. Then after the policy renewed in 2023, they started denying claims for the same lymphoma that they were approving previous claims for, citing the vomiting as a pre-existing condition. I feel like they pulled the rug from under me and that has left a bitter taste in my mouth.

As with any insurance, when they deny your claim or you don't have to use it, it's a "waste of money". But when you have to use it and they come through, you'll be glad you had it. My insight is that one visit to the emergency vet (I'm in the NJ/NYC area) will easily rack up bills to the thousands. For Flora, her endoscopy, ultrasounds, bloodwork, chemo that her insurance company paid out far exceeded the premiums that I paid. In fact, if I had insurance for the full 6 years that we had her, I think we would still come out ahead. My only advice is that if you choose to get pet insurance, get a reputable one that is easy to work with and meets your budget. With pet insurance, you're pretty much stuck with them (especially if they pay something out). Switching would mean that the new company would not cover any that the previous one did, with the pre-existing conditions clause. Sorry for being long winded, but I hope that helps.

 

[FlorasDad]

All five of my cats have insurance, and I will be back a little bit later today to try to add a little more to this if I feel that I can in anyway be helpful.

if you are in the United States, pet health insurance does have to answer to your state insurance board or whichever body governs insurance in your state. You can file a complaint or open a case with them. I threatened to do this once over a pet insurance claim in which the company insisted repeatedly that they had not received an extremely important piece of diagnostic information. I never actually had to do this though, because when I told him that they had five days to figure this out, or I would hit “submit”on the complaint they somehow saw their way through it.

I understand that you are concerned about being asked for reimbursement on what they might call an incorrectly submitted or falsified claim.

I am very sorry for your loss of Flora.

Thank you. Yes, that is the only reason why I have not mentioned to them the fact that they approved and paid claims pertaining to vomiting and lymphoma before. I simply submitted the original documentation and invoices as I would do any claim, so I feel the onus would be on them as I was just doing my part honestly. I am just not sure if they could do something like that and didn't want to open a can of worms...

 

[fionasmom]

I am just not sure if they could do something like that and didn't want to open a can of worms...

I certainly get that. With compensation for injury or loss, such as worker's comp payouts, the insurance companies do have the right to ask for their portion to be paid back from the settlement, and in general "overpayment" may be required to be returned to the company, but there is a statute of limitations in some states for the filing of this claim on the part of the company. It might be worth calling your state insurance board and asking where they think you might stand before/if filing a claim.

I feel that they are misconstruing the vet notes as a means to deny the claim.

Not impossible given that, as was said, all cats throw up and hairballs were cited previously regarding Flora.

 

[Joxer]

Mathematically speaking, all insurance is a bad deal unless a third party is subsidizing it. With private human health insurance, about 30% of premiums go to insurance company administrative costs.

You have to decide how much "peace of mind" (ie regular, predictable premium bills instead of possibly very high, unpredictable emergency medical bills) is worth to you. There is probably not a single answer that is right for everyone.

For myself and my cats, the fact that I would likely end up paying more overall by purchasing insurance, combined with the hassle of submitting bills for reimbursement and dealing with denied claims, leads me to forego pet health insurance.

Denying a cancer treatment claim because of prior vomiting sounds like something that is probably illegal in most states, even for pet health insurance. Vomiting is far too vague and common a symptom to be evidence of any pre-existing condition except being alive. Imagine being denied lung cancer treatment at age 50 because your pediatrician heard you coughing when you were in kindergarten.

 

[FlorasDad]

Wanted to give an update, good news! The appeal was successful and they paid out the most recent claim they denied. They also retroactively opened and approved the initial claim they denied on the basis of pre-existing conditions. Good way to start the new year

 

[fionasmom]

Great news! Thank you for letting us know!