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 Posted: Tue Oct 27, 2009 4:18 pm Post subject: My insurance company is wrongfully denying a claim. What ca |
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| Insurance policy is for my dog. Insurer is ASPCA Pet Insurance. My dog is displaying strange behaviors and so we took her to the vet who performed an MRI (which cost over $2,000). The MRI revealed a growth at the base of her skull, which is common in her breed (~95% of cavaliers have this) and which can cause problems. However, my dog does not show symptoms of this problem. Her behaviors do not appear to be connected to this illness or respond to treatment for this illness. The doctor has concluded (as have I) that the growth is not related to her problem. The insurance company claims that it's a congenital or hereditary disease so it's not covered. The statement is ludicruous because we don't even know what IT is, so how can they say it's congenital. The argument is the equivalent to me breaking my foot playing football, having the doctor x-ray my foot and seeing, aside from the break, an abnormality in my foot (that 95% of humans have) and the insurance company saying therefore we're not covering your broken foot. |
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roybendor
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| Posted: Tue Oct 27, 2009 7:39 pm Post subject: |
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| Based up on your story, I am pretty sure there is more to it. |
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Trench
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| Posted: Tue Oct 27, 2009 9:06 pm Post subject: |
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| You're not clear on what they are denying... the problem of the strange behavior or the growth. |
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tcope
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| Posted: Tue Oct 27, 2009 11:12 pm Post subject: |
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| Quote: | | The statement is ludicruous because we don't even know what IT is, so how can they say it's congenital |
Well, if NO BODY (including the vet) knows what it is, then they cannot 100% say that it is NOT congentital..how can you expect them to pay this without a diagnosis, that you yourself admit to not having...
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Lori
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| Posted: Wed Nov 11, 2009 3:02 pm Post subject: |
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In response to Lori: "how can you expect them to pay this without a diagnosis, that you yourself admit to not having..."
My policy does not say "we do not cover incomplete diagnoses." It says that it does not cover "congenital or hereditary" diseases. They are responsible for paying out any medical expenses legitimately incurred in diagnosis or treatment of my covered pet unless they can exclude it for one of the outlined provisions. So I don't have to prove what it is, they have to.
In response to trench and tcope:
They are denying the claim for the MRI and doctor's visit.
Because the malformation in her head (which is present in 95% of her breed) is congenital or hereditary, and because it was discovered with the MRI they are denying the claim for the MRI and the visit.
They sent me a letter saying that the malformation causes all kinds of diseases, that the vet in her report noted that she couldn't rule it out, and that my dog's behavior could be the result of that. However all the diseases they mention have clear associated symptoms, none of which my dog is demonstrating, and my dog's behavior isn't a symptom of those diseases. However, it is theoretically possible...
Again, this seems totally illogical to me. |
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roybendor
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| Posted: Wed Nov 11, 2009 3:58 pm Post subject: |
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| Quote: | | It says that it does not cover "congenital or hereditary" diseases. They are responsible for paying out any medical expenses legitimately incurred in diagnosis or treatment of my covered pet unless they can exclude it for one of the outlined provisions. |
You are incorrect. The policy offers coverage for certain things. At this time you've not provided any information (a diagnosis) to show that the treatment was for a covered item. It's the insured's responsibility to to provide information to support their claim. The claim of "I don't know what the illness is" does not shift the burden of that proof of coverage to the insurance company. Using the same information, how can you say that this is a covered illness? You can't.
But here is the important part: | Quote: | | They are denying the claim for the MRI and doctor's visit. |
and | Quote: | | The MRI revealed a growth at the base of her skull, which is common in her breed (~95% of cavaliers have this) and which can cause problems. However, my dog does not show symptoms of this problem. Her behaviors do not appear to be connected to this illness or respond to treatment for this illness. The doctor has concluded (as have I) that the growth is not related to her problem. |
So the only issue is that they are not covering the MRI and doctors visit? Are you agreeing that the growth is congenital or hereditary? This statement would seem to indicate this: | Quote: | | which is present in 95% of her breed |
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tcope
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| Posted: Thu Nov 12, 2009 12:36 am Post subject: |
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| Quote: | | So I don't have to prove what it is, they have to |
I'm sorry but your are incorrect, you have to prove (your claim and that) it is NOT a | Quote: | | "congenital or hereditary" diseases |
It is ALWAYS the insured (or claimants) burden to PROVE their claim.
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Lori
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heidrek
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| Posted: Thu Nov 12, 2009 11:27 am Post subject: |
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| Quote: | | then couldn't they simply claim that any and all illnesses (other than broken bones etc) MAY be related to this growth and therefore decline to cover anything? |
It is the case, and I suppose...but it shouldn't be that difficult to determine it either is or is not congenital and/or hereditary.
| Quote: | | Seems like a pretty good escape clause for them if that so and more or less renders the policy worthless, no? |
All insurance policys (that I've ever read) give you coverage in one area, and take the majority of that away in another area (exclusions)..I'm having a hard time understanding why it's so hard to say if it hereditary or not?
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Lori
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| Posted: Thu Nov 12, 2009 8:15 pm Post subject: |
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the issue isn't whether the growth is hereditary or not, it's pretty much established that it is - it's whether the growth and the behaviour or problems are related.
There is a growth, and issues relating to that wouldn't be covered as it's a congenital/hereditary issue, but there is nothing to say that the problems the dog is experiencing are realted to that growth or not other than conjecture.
In fact treating the growth seems to have no effect on the issue at hand one way or another, which suggests that it is not related, or the cause of the problem.
My point was that with a "growth" the possible symptoms associated with it would include just about anything. The insurer could claim that almost any illness or symptoms COULD be related to the growth, however unlikely, and therefore avoid cover, making the policy next to useless.
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heidrek
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| Posted: Fri Nov 13, 2009 11:19 am Post subject: |
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Ok, I get your point...but my point is, unless and until you have a diagnosis for the issue at hand and that diagnosis is NOT a congenital or hereditary disease that carrier isn't going to pay a dime.
Again, you are required to prove your loss, and you cannot prove it's not genetic.
I frankly don't understand why or how a vet can't give you a diagnosis. 
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Lori
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| Posted: Fri Nov 13, 2009 9:35 pm Post subject: |
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I don't understand or agree with your assessment of the burden of proof.
My policy states:
"Except as stated elsewhere in this plan, we will pay the reasonable costs you incur for veterinarian fees as
the result of illness or injury to your pet that occurs and is treated during the Plan Period. These fees may
include costs for ... 2. X-rays, diagnostic procedures, and laboratory tests necessary to diagnose or treat an illness or injury;"
Then there is a section called "expenses not covered."
Based on my reading, I would be responsible SOLELY for proving that my dog has had veterinary fees. Then it is the responsibility of the insurance provider to qualify the treatments as something exclusionary. If it's not excluded it's covered. How am I supposed to prove what my dog has? I'm not a veterinarian.
Furthermore, my dog has a diagnosis. It's a rare byt known disease. However, the cause is unknown. There are LOTS of diseases in humans and animals for which the cause is unknown. Cancer? Alzheimers? Given that the cause is unknown it is impossible to rule out congenital or hereditary triggers or predispositions. But that shouldn't make it excludable. Almost everything has the possibility of being related to congenital or hereditary predispositions. |
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roybendor
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| Posted: Fri Nov 13, 2009 11:04 pm Post subject: |
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| Quote: | | There are LOTS of diseases in humans and animals for which the cause is unknown. Cancer? Alzheimers? |
But the big difference in the policy language between the two, is that a health policy does not exclude genetic disorders..your pet policy (apparently) does..
See here is the problem...(and by the way I totally get your frustration...I didn't write or sell the policy I'm just trying to explain to you the reasoning behind it).. | Quote: | | Based on my reading, I would be responsible SOLELY for proving that my dog has had veterinary fees. |
Well of course you are who else would submit the bills? Your vet (and his/her report) is responsible to diagnosis what is found, your vet told your insurance carrier that | Quote: | | the vet in her report noted that she couldn't rule it out, and that my dog's behavior could be the result of that. |
It is my understanding from your posts that the ONLY thing that showed up in the MRI was | Quote: | | the malformation in her head (which is present in 95% of her breed) is congenital or hereditary, |
| Quote: | | The MRI revealed a growth at the base of her skull, which is common in her breed (~95% of cavaliers have this |
So...if the only thing/diagnosis determined from the office visit and the MRI is a congential defect. The policy flat denies it..I'm sorry but that's what the policy you purchased says. Ins. policys are a contract of adhesion, meaning you are adhering to EVERYTHING in that policy..
| Quote: | | However all the diseases they mention have clear associated symptoms, none of which my dog is demonstrating, and my dog's behavior isn't a symptom of those diseases. |
If this above statement is true, then frankly your vet is who you need to be ticked off at, she's the one that told your carrier she couldn't rule out genetic defect, and further (apparently) she either doesn't share this view point with you or most certainly did not state this in the report she sent to your carrier ...since in her report she states | Quote: | | the malformation causes all kinds of diseases, that the vet in her report noted that she couldn't rule it out, and that my dog's behavior could be the result of that |
Honestly, that one statement, of not being able to rule out genetics, no diagnosis, and the behavior of your dog could be from the genetic growth, sunk you claim.
You've got me confused with the following statements please clear this up..
| Quote: | | The insurance company claims that it's a congenital or hereditary disease so it's not covered. The statement is ludicruous because we don't even know what IT is |
Then you say, | Quote: | | Furthermore, my dog has a diagnosis. It's a rare byt known disease |
Well? What is it and why did you say it wasn't diagnosised? or that no one knows what the trouble is? If the dog has a rare disease, that is NOT genetic, then the treatment for that disease would be covered...
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Lori
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| Posted: Fri Nov 13, 2009 11:12 pm Post subject: |
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Sorry Heidrek, I missed this post.. | Quote: | | Question Lori: If this is the case, then couldn't they simply claim that any and all illnesses (other than broken bones etc) MAY be related to this growth and therefore decline to cover anything? |
I suppose they could. It's (IMO) no different though, than say a homeowners policy that covers water damage, but excludes water damage if it was not 'sudden and accidental' or if it occured due to 'gradual deterioration'...all policys have exclusions..I've never seen a policy without any. As you know it's the insured's job to read their policy and understand it.. 
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Lori
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| Posted: Fri Nov 13, 2009 11:14 pm Post subject: |
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My dog has "Fly Catching Syndrome". That's the disease. But it's basically a disease that is named after the symptom. The cause is unknown. In theory it could be genetic, it could be physiological, it could be behavioral. The disease exists in multiple breeds (so ti's unlikely genetic; also those breeds don't have chiara malformations) and it has been treated successfully/unsuccessfully in many different ways.
So basically, my dog does have a growth on her head. That growth is clearly genetic (as is every other part of her brain that came up in the MRI), it just has nothing to do with her symptoms. My doctor can't rule out anything (including "spirits" controlling my dog) because she can't prove what it is. That's a pretty common thing in medicine. There are often dozens of possibilities, some more likely than others.
Here one possibility is something genetic. It's just REALLY unlikely. But according to my insurance company - and apparently your - logic the fact that it could be genetic means that it gets to be ruled out. Pretty much anything could be genetic. And even things that don't seem genetic (like liver failure, kidney failure, gastro-intestinal problems, etc. etc. etc.) have genetic predispositions. |
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roybendor
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