Pre-ex conditions

Pre-Existing Conditions

1. The condition is curable and the policyholder doesn't understand how something curable is pre-existing.
2. The condition was not officially diagnosed prior to the policy effective date or during the 14-day waiting period and only previously showed symptoms.
3. The policyholder was wholly unaware that pre-existing conditions were excluded by the policy.
4. The policyholder was unaware that their veterinarian even found or diagnosed the condition.

Generally speaking, denying a claim due to a pre-existing condition tends to go 4 different ways when conversing with a policyholder:

Explaining pre-existing conditions to a policyholder might include referencing the chronic and curable definitions. But it's important that you make sure the policy includes curable conditions before mentioning it to a policyholder. At this time all states offer curable conditions, but some policies won't include them until their policy renews. To find this information, go to the pet medical history tab in the pre-existing determination box and look for "Coverage for Curable" There will either be a red x that says "policy does not include coverage for curable conditions" or a green checkmark that says after XX/XX/XXX, policy includes coverage for curable conditions"

Curable Conditions

You will educate the policyholder on:

• Chronic and curable definitions (if applicable)
• What a pre-existing condition means and discussing their particular policy effective date and/or applicable waiting periods and how it affected the pre-existing determination.

The conversation should involve weaving the policy into their medical records so that as you walk them through their medical records and the policy, they all tie together. The denial letters and denial email will already help to weave the policy and the condition together, so the skill will need to be honed for phone conversations and if the policyholder has any follow-up questions.

Explaining Pre-ex Conditions to Policyholders just requires education!

TL;DR: If one side of the body shows signs of a bilateral condition before start date and through the applicable waiting period the opposite side won’t be covered either. This means when discussing a claim denied due to a pre-ex bilateral condition you will need to refer to both the pre-ex conditions and bilateral conditions section of the policy in order to give the policyholder the full picture.

Bilateral Conditions