Premium & Professional Presentation

Claim Overview subsuctions

Claim History

Policy Coverages

Claim Media

Claim Overview

index

Claim Medical Condition

Pre-Existing Determination

Waiting Period Eligibily Dates

Date of Vet Visit

Date of Noticing Illness

Claim Lifecycle

You likely reviewed all this info as the Pet Specialist and you will continue to do so as the Claims Advocate, but for different reasons. Because of your familiarity, we will not go through each section but will call out a few specifically in the next slides!

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This section contains all of the dates regarding the policy and that specific claim. This includes:

• Policy effective date
• Waiver exam date (if under the Cian Policy and A Waiver was submitted)
• Waiting period eligibility dates (AWP, IWP, CCLWP)
• If it is brand new under the Cian policy this section will include the OWP instead of the CCLWP and indicate if the WP has been waived or has a pending waiver)

• Date of vet visit
• Date of noticing illness
• Claim started
• Claim submitted
• Claim settled (when settled)

Claim Lifecycle

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The date of noticing illness will only appear for illness claims (for accident claims it will bereplaced with date of accident occurance), but it will be a date to take note of, especially for those claims that are close to the end of one of the waiting periods. We will talk about handling claims in these types of scenarios later on in training. So why is this date important? Wouldn't it just be the same as the date of the vet visit? NOPE! This date is very important since we do not cover pre-existing conditions, so even if the vet visit occurred after the policy effective date or after the waiting period was over, if the onset(signs/symptoms) of the accident or illness was before those dates that will affect the claim outcome. Verifying this date may require additional investigation like looking at the DOL notes and/or the policyholder video or voice memo in the TL;DR section as well! If you need to edit this, similar to editing the claim type we discussed briefly in the last section just click 'edit the claim details' in the action drop-down in the top right corner of Blender!

Date of Noticing Illness

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This one is self-explanatory we know, but it is particularly relevant for a Claims Advocate and deserves a call out as it will be important in your first assigned task!Ask yourself : • Is the DOL outside of the WP? • Is the DOL close to the WPs If the PH submitted a claim for several listed DOLs or the pet was hospitalized for a few days, make sure the DOL on the claim is the earliest date applicable(the day they presented). For example, if a puppy went to the emergency vet for parvo and was hospitalized from 11/12/22-11/20/22 the date of the claim (even if there are multiple invoices for parvo associated with the claim) the date of the vet visit should be 11/12/22. If you need to edit this, similar to editing the claim type we discussed briefly in the last section, just click 'edit the claim details' in the action drop-down in the top right corner of Blender!

Date Of Vet Visit

Cian

OG

This section is being called out as a reminder of what will be included in this section for the OG policy vs a Cian policy. If the policy was previously an OG policy and renewed into the Cian policy, the Claim Lifecycle section will always show the OG waiting periods ( IE: AWP and CCLWP) and not the Cian waiting periods (IE OWP). This means you can not fully rely on this section in Blender as a flag for when we are working with Cian policy or an OG policy.

Waiting period eligibility dates

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Claim Media, Policy coverage & Claim History

Pro Tip

The 'Claim Media' subsection will only appear if the policyholder recorded more than one video/audio. If only one video/audio was taken, this section will not appear. Keep in mind that you will want to check the deleted videos/audio quickly to ensure there are no gaps in the policyholder's story. This subsection allows for that.

Claim Media

The 'Policy Coverages' subsection is where you can see their coinsurance, deductible, and annual limit. This subsection will also show if the policy has any add-ons.Keep this subsection in mind when it comes to reviewing the claim items in another task. But don't worry about memorizing the info! You can always come back to this subsection.

Policy Coverages

Multiple Claims on the Same Date of Loss Alerts

1+ Claims

1 Claim

The 'Claim History' subsection is just that - that pets claim history. This is a subsection that may or may not appear depending on if the pet has had a claim previously. If the pet had no prior claims, it won't show up. You will see whether there are prior claims or currently open claims, their assignee(s), the prior date of loss(es), the medical condition(s), and whether those prior claim(s) were eligible for coverage or not. Protip: You can look at past claims invoices/vet notes to see if there are clinics we might be missing records for if you later determine we need MR.

Claim History

Claim Medical Condition

Pre-Existing Determination

As a former Pet Specialist, you may not have paid a ton of attention to these two sections of the Claim Overview section, but as a Claim Advocate, they are an important part of the claims process as you will learn later on in training.

Pre-Existing Determination and Claim Medical Condition

At first glance, these 3 sections of the Claim Overview may not seem as important as others, but that could not be more wrong! Even if you don't need the info from these sections at the time of review, we guarantee there will be claims where you need to revisit this section to refresh yourself on the part of the claim.

Last, but not least, is the 'Claim Medical Conditions' subsection. If you're reviewing this at the beginning of the claim, this is the condition the policyholder entered. This section cannot be edited. Remember, this is just for informational purposes. The Claims Advocate can change the condition, link any claims, and determine eligibility in a later task. Once the Claims Advocate has updated this information at a different step within the workflow this subsection will adjust automatically.

Claim Medical Condition

As you know there are no waiting period waiver dates to take note of when it comes to OG policies, all you need to pay special attention to (along with what we have already talked about in this course) is the accident, illness, and cruciate ligament eligible from dates, the tags of eligible and not eligible

OG Policy

Cian Policy

There are three scenarios regarding the waiting periods and the waiver applicable to Cian policies you need to be aware of:1.Waiting Period Waiver Hasn't Been Reviewed

• If the waiting period waiver form is attached to the policy but it's not yet been approved/declined by the Underwriting team, a banner will appear on the Claim Lifecycle or Pre-Approval Lifecycle tasks. It will state that a waiting period waiver was submitted but hasn't been reviewed (as seen in the screenshot above). If you see this alert banner, please reach out to the Underwriting team to let them know that a claim has been submitted. Please do not proceed with the claim until the Underwriting team has had a chance to review the waiver as that may impact the claim determination.

2. Waiting Period Waiver Has Been Reviewed

• If the waiting period waiver was previously approved by the Underwriting team, there will be an additional date listed for the waiting period waiver exam, but it will only be there if the waiver was approved by the Underwriting team.
• The rows that show the applicable waiting period dates will have a strikethrough of what the date would have been if no waiver were submitted. Just below that original date, you'll see the new eligibility date, which will be one day after the exam date. There will also be green tags next to each of the new dates stating 'Waived.'

3. The 'Eligible' and 'Not Eligible' tags next to the waiting periods will still appear if the waiting periods weren't waived

• Additionally, you may have noticed in the screenshot there is a bug where the crutiate waiting period dates are listed in the claim lifecycle section, but just know for Cian policies this waiting period does not apply.

Multiple Claims on the Same Date of Loss Alert:

The Claims History task may also show an alert if there are multiple claims with the same date of loss (DOL). This is meant to assist Claim Advocates in catching potential duplicate claims. This alert does not guarantee that the claims are duplicates, but Claim Advocates should be aware of that possibility..

As a Pet Specialist, you probably didn't frequently review this section, if ever. However, as a Claims Advocate, this particular section holds significant importance. The 'Pre-Existing Determination' subsection is pulling the pre-existing conditions table that's on the 'Pet Medical History' tab for a quick and easy view of any pre-existing conditions within the 'Workflows' tab. It will also include if a medical record review was previously completed or not. This will show up even if no pre-existing determinations have been identified in the past. It will simply say 'No Pre-Existing Determination Yet.'

Pre-Existing Determination