by roybendor » Tue Oct 27, 2009 04:18 pm
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.
Posted: Fri Nov 13, 2009 09:35 pm Post Subject:
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.
Posted: Fri Nov 13, 2009 11:04 pm Post Subject:
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)..
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 thatthe 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 wasthe malformation in her head (which is present in 95% of her breed) is congenital or hereditary,
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..
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 statesthe 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..
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,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...Posted: Fri Nov 13, 2009 11:12 pm Post Subject:
Sorry Heidrek, I missed this post..
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.. :wink:Posted: Fri Nov 13, 2009 11:14 pm Post Subject:
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.
Posted: Fri Nov 13, 2009 11:32 pm Post Subject:
Well this is bad news...I googled this and the very first one I looked at said this...
http://www.cavalierhealth.org/flycatchers.htm#Current_Research
Cavalier King Charles spaniels are pre-disposed to a disorder called flycatcher's syndrome. It is believed to be caused by a mutation in a specific gene which the dogs have inherited from their parents.
I'm sorry but no matter how you cut it that is without a doubt genetic..More bad news, it further states,
The Canine Inherited Disorders Database (www.upei.ca/~cidd/intro.htm) recommends that Cavaliers which have had seizures should not be bred, nor should their parents and siblings.
From what I've read (and I read PLENTY)...The growth and this rouge gene/genetic predisposition to this, have nothing to do with each other...but the problem is, this too (your dogs condition) is CLEARLY thought to be genetic. So anything associated with the treatment of this disorder would be excluded in your policy.The disease exists in multiple breeds
None as much as the King Charlesso ti's unlikely genetic; also those breeds don't have chiara malformations
That isn't what causes this..it's geneic..the other theory (re: behavioral) still doesn't remove it from genetics.Pretty much anything could be genetic
Why don't you google this disorder and see what pops up, I'll tell ya' "Cavalier King Charles spaniels"...it just has nothing to do with her symptoms.
I'm sorry but not according to all the vet articles I just read..Try to remember...I'm not your enemy...I have NOTHING to gain by telling you this...
How old is your dog? Have you talked to the breeder?
Posted: Sat Nov 14, 2009 04:44 pm Post Subject:
To answer your direct question, She's a year and a half. No other dog in her long lineage has this issue. Her brother (who we have) doesn't have any issues.
As for your research, I've read that all. It's entirely speculative. There is no actual research or demonstrated treatment. I've talked to the leading researcher in the world on these types of disorders and he agrees that the genetic component is conjecture (i.e. all doctors jump to genetics when they see patterns, even if they can't prove it).
He believes - and has been successfully treating my dog - that the disease is physiological (a chemical imbalance). Chemical imbalances may have a genetic predispositions but so does almost every disease - depression, anemia, blood clots, seizures, heart disease, cancer, etc. etc.
Anyway, we don't need to have this back and forth anymore. Thanks for taking the time. I don't think I'm going to get any help here.
I've had two additional vets look at her. BOTH agree that there is NO evidence to conclude a genetic or congenital disease other than conjecture, which could be applied to ANYTHING unexplainable. My original doctor feels the same way and is writing to clarify with the insurance company that she was stating it as a POSSIBILITY but not LIKELY.
Posted: Sun Nov 15, 2009 12:40 am Post Subject:
You got plenty of help here, you just didn't get the answer you wanted, and I'm sorry that you can't see that difference.
Posted: Sun Nov 15, 2009 06:40 am Post Subject:
That's quite an insulting response. I got your opinion, which you are entitled to, but no real evidence or facts either in support or contravention. I respect your opinion but by no means did I learn anything new or hear any new arguments. Your opinion just makes the count 4-2 (me and three veterinarians vs. you and the insurance company). I apologize if you are insulted but all I had here was a debate with another party. I consider your arguments insensible. Under your definitions, nobody would ever purchase insurance, as anything that couldn't be 100% proven as non-congenital would not be covered. I can't see the market demanding such a product, certainly not at the prices of insurance. You're still entitled to that opinion, but I don't have to accept it or consider it a valuable contribution. I'm sorry you can't see that.
Posted: Sun Nov 15, 2009 12:50 pm Post Subject:
That's quite an insulting response
It wasn't meant to be, and frankly I think you've been the same.Look all I'm trying to get across to you is this...you're ticked off because you paid 2k (plus) for a dogs mri and thought your carrier would pay for it. (I'd be pretty disappointed too that's a lot of money !) They didn't and won't because your vet stated (and all the info I've read on the net) say this is a genetic disorder...your policy excludes that. Unless and until you can get some vets to say that it in no way, shape or form can this be genetic they aren't going to pay it. That's the way the policy you purchased was written. I didn't write or sell you this policy nor did I handle your claim. I'm just telling you why they ruled that way...and the reason they did is because your vet (basically) agree with them. You can bet they have vets on staff as well to handle and research claims, and apparently they are of the same opinion.
IMO, your only recourse is to (attempt) to sue this carrier for breach of contract or vicaious refusal to pay. But again my opinion based on all I've read, you don't have a shot.
If this policy is junk, it's junk. Cancel it.
Posted: Sun Nov 29, 2009 10:12 am Post Subject: This thread is way too long!
Roy,
You read the contract one way -- and your claim is payable, the company reads it another way -- and the claim is not. This is the classic tale of a contract of adhesion, which nearly all insurance policies are.
There are two possible solutions: (1) file a complaint with your state's insurance regulator (Dept of Insurance in most states), and they will investigate for unfair claims practices. That could chill the ice water in a claims examiner's veins. (2) you could hire an attorney to sue the insurer for breach of contract, and leave the interpretation of the contract up to a judge (I would avoid a jury on this -- you get a bunch of cat lovers, and you're likely 'toast'). If the judge finds there is an ambiguity, it must be tossed in favor of the party who did not write the contract (the insurer).
Most people don't know about turning to their Insurance Commissioner for assistance.
Add your comment