To cover or not to cover?
Blue Banner Eligible?
Pet Signalment
No FU vs Pre-X
WILD CARD
100

Lacy has been limping and the reason is unknown. The invoice has: bloodwork, 4dx, & rads. Is the 4dx covered?

Yes, it's being used as a r/o 

100

Enrolled 12/2019. Claim is dated 2/2020. Pet was 2yrs old at enrollment

INV:Induce vomiting, activated charcoal, Rx Cerenia

Yes! 

This is a toxicity claim

100

Fifi was enrolled as a small mixed breed and her medical records have her listed as a bichon mix. Do we need to update the breed?

No. 

A mix is a mix

100

Tony has an otitis on 5/1/2020. He enrolled on 5/15/2020. What is the dermination?

No follow up. This has a high chance of resolution and would be eligible for future coverage

100

Pepper submits a claim for dental, rads, and extractions. What do we need?

DOS MR

200

Tyson has a fecal and Rx Metronidazole. Would we cover the fecal?

Yes, since there is medication being sent for gastritis.

200

Enrolled 1/1/2020, claim date is 9/1/2020. Pet was 6 months old at enrollment.

INV: Rads, Rx Doxycycline, Theophylline 

Yes! We are outside of 6 months and with the contents of the INV we can infer that these are thoracic rads. 

200

Jojo was enrolled with a DOB of 6/1/2017 and her medical records show a DOB of 10/1/2017. Do we need to update the age?

No. 

DOB's can be within 6 months. 

200

Vision has conjunctivitis on 2/10/2019. He enrolled on 2/11/2019. What is the determination?

No follow up. Even though this is right before enrollment, this is a condition that has a high chance of resolution. 

200
Ronan enrolled on 1/1/2020 as a 7yr old Corgi. On 2/2/2021 he submits a claim for an FHO. Is this covered?

No, an FHO is for hip dysplasia and Ronan was over 6 yrs old when we he enrolled. 

Bonus: Why does that matter?

300

Minnie gets acupuncture done monthly as maintenance and has no underlying conditions. Is the acupuncture covered?

No, we only cover when it's being used for a covered condition.

300

Enrolled 10/4/2015. Claim date is 1/27/2020. Pet was 1 yr old at enrollment. 

INV: Rads, Rx Metacam

No. These rads w/ metacam are red flag items and we need full MR

300

Scooter was enrolled as a DSH and medical records show he is a Chihuahua. What do we need to update?

We need to update the species to dog and enter breed as Chihuahua.

300

Mantis was positive for Giardia on 2/10/2017. She enrolled on 5/10/2017. What is the determination?

No follow up. This has a high chance of resolution. 

300

Drax has pre-existing IVDD on T1-T4. We get a claim for a hemilaminectomy on L2-L5. Can we cover this?

Yes! We view IVDD as "separate" conditions if it shows up in different areas. So the new area would be eligible for coverage.

400

Jade was spayed during enrollment. Her incision opened up after playing ball and needed to have the incision repaired. Would we cover this?

No. This is a complication of a condition excluded from our policy. 

400

Enrolled 2/3/2019. Claim date is 5/1/2020. Pet was 7 when enrolled. 

INV: ACTH stim, Rx Trilostane. 

No. Since this pet was over 6 when enrolling the blue banner would not pop up. 

400

Dobby was enrolled with a DOB of 1/2018 and medical records show a DOB of 8/2017. Do we need to update the age?

No. Age is within 6 months 

400

Quill has stomatitis on 11/1/2020. He enrolled on 11/30/2020. What is the determination?

Pre-existing. It is a chronic condition that can go on for months or years.

400

Shuri is a 8yr old labrador mix. She enrolled on 5/1/2020. MR submitted 10/1/2014-1/22/2020 and DOS MR. What can we use as EE?

Since EE does not fall within required time frame we have to use DOS which means anything noted would be excluded from coverage. 

500

Odie has a pre-x right CCL tear and pre-x right MPL. On exam he has a signs of a cranial drawer on the left rear. Surgery is recommended. Could we cover this?

No! Cranial drawer is a symptom of a CCL tear and we have a bilateral exclusion. 

500

Pet enrolled 5/1/2017. Claim date 2/15/2018. Pet was 1.5 yrs old when enrolled

INV: Catheter Peripheral intravenous, Vincristine Injection, Biohazard Disposal Fee 

No. These are red flag items and we need FULL MR. 


Bonus points for condition!

500

Alice enrolled as a Cavapoo. The medical records state she is a poodle mix. Do we need to update the breed?

No. These are both mixed breeds. 

500

Pietro has a urinary obstruction on 9/1/2017. He enrolled on 4/7/2020. What is the determination? 

Pre-existing

Why?

500

During Pepper's MRR, it's noted 9 months prior to she was MRs were sent Trupanion. What do we do?

Nothing. If medical records reference another insurance policy within the past 6 months (e.g. “Faxed medical records to Trupanion.”), OR if we ever receive a claim form from another pet insurance company for that particular pet, we then need to confirm whether that policy is still active or not. 

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