Pet Specialist CE - Claim Investigation Guidelines

Claim Investigation Guidelines

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Why Do We Do Claim Investigations?

The Claim Investigation process is setting everyone up for success in the future. This includes success for:

• Our Policyholders: This provides them with a consistent, accurate, and efficient process. Instead of asking for medical records to perform an MRR for any first illness claim, we can evaluate whether or not it needs an MRR based on Claim Investigation guidelines.
• Claim Advocates: Claim inventories will only continue to climb as Lemonade grows. Assessing policies through the lens of the Claim Investigation guidelines will allow for more efficient and accurate claim settlements in both the short and long term, which will help ease the stress of inventories Claim Advocates will need to handle.
• Lemonade: Lemonade Pet has grown exponentially over the last few years and is expected to continue to have massive growth. This will of course lead to a higher inventory of claims. The answer to higher claim inventories isn't hiring large swaths of Claim Advocates. Instead, the Claim Investigation will help Lemonade work smarter, not harder, with the staffing that we currently have (while not overloading the current staff).

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Guidelines, Not Rules?

Claim Investigation is guided by established best practices rather than rigid rules. In pet insurance, there is no true “one-size-fits-all” scenario. Every claim must be evaluated in context, considering factors such as:

• The pet’s breed
• The policy duration
• The condition being claimed
• The supporting evidence in the file.

Relying solely on strict rules can limit fair and accurate decision-making. Guidelines, on the other hand, provide structure while still allowing for critical thinking, which is at the heart of the Claim Investigation process.

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Claim Types

Each type of claim has its own set of guidelines that Claim Advocates follow. This is because each claim type carries different considerations and potential challenges that must be addressed.

Preventative Claims

Accident Claims

Illness Claims

Accident claims require some claim investigation due to having a shorter or no waiting period to protect us from pre-existing conditions. Click below for more information!

Illness claims require a more robust investigation since Claim Advocates must take the policy lenght and "Advanced Health Conditions" into account. Click below for more information!

Preventative claims require minimal to no investigation. Click below for more information!

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When Is An MRR NOT Needed?

When reviewing an Illness claim, an MRR is NOT needed in the following circumstances per Claim Investigation guidelines:

• It's the first Illness claim greater than 12 months after the PED with no chronic indicators. We will complete the MRR with the information we have in this scenario.
• It's the first Illness claim but it's less than 12 months after the PED but over 100 days since the PED and it's not for an Advanced Health Conditions. We will move forward with this claim and not complete this MRR.
• Chronic indicators include medication refills with no sign of when they were originally prescribed, there were no visits to a veterinary specialist, and no claim documentation indicating that this has been an ongoing issue.

We'll discuss chronic indicators and Advanced Health Conditions next!

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Advanced Health Condition vs. Chronic Indicators

What's an Advanced Health Condition (AHC) and what's a chronic indicator? Both are important to take into account during Claim Investigations.

AHC

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An AHC may have chronic indicators or it may not

A condition that has indications of being chronic may not be an AHC

Conditions that have multiple symptoms

The first illness visit is for a veterinary specialist

A condition that will likely need extensive follow up care or ongoing care

The illness claim is for a prescription refill

A condition that may have been "quiet" and not needed treatment in the past and may forego treatment for some time after diagnosis

There is mention in the claim media or policyholder correspondence that the pet has a history of a certain condition

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Advanced Health Conditions

The following are all of the AHCs Pet Leadership has included in the Claim Investigation guidelines:

• Musculoskeletal (CCL, MPL, etc.)
• This excludes true accidents (fractures)
• Masses
• This excludes fast growing cancerous masses such as osteosarcoma
• Urinary issues specifically
• In cats such as UTI, crystals, FLUTD, UO
• Recessed vulva in female dogs

• Heart disease
• Murmurs or other heart disease
• Brachycephalic disorders
• Allergies and dermatitis
• Neurologic conditions
• This also includes IVDD or generalied neck/back pain
• Dental illnesses
• Feline asthma
• Hernias
• Endocrine diseases
• Cataracts and glaucoma
• Liver shunt
• Cryptorchidism

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When Is An MRR Needed?

When reviewing an Illness claim, an MRR is needed in the following circumstances per Claim Investigation guidelines:

• Claims less than 100 days from PED
• The condition does not matter
• Claims between day 100-364 for Advanced Health Conditions
• Claims with chronic indicators
• Time from policy effective date does not typically matter (there are always exceptions)
• Follow up claims with continued treatment
• Claims for conditions that are User Reported Conditions

No chronic indicators...

Claim is 250 days since PEd....

we need an mrr!

Claim is for seizures...

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What About Breed?

As mentioned previously, the breed of the pet is factored into the Claim Investigation process. While we will never be discriminatory against a certain breed of cat or dog, we know that certain breeds are more susceptible to specific illnesses.

• Brachycephalic breeds are more likely to have BAOS
• Golden Retrievers have a high chance of developing cancer
• Main Coons are highly likely to have heart disease
• Boxers are highly likely to have heart disease and/or cancer
• Small dog breeds are more prone to luxating patellas

As you can see, those conditions have already been identified as AHCs. As such, Claim Advocates do not necessarily need to worry about the breed and how that will affect their Claim Investigation. However, Claim Advocates are still aware if that particular breed of animal is highly susceptible to the claimed medical condition.

I'm a frenchie... By the time i turned 4 years old, i had stenotic nares and elongated palate repair, diagnosed with grade 2 Mpls, receive monthly cytopoint injections for my allergies, and just had a hemi for ivdd. but i'm fiiiiiiine.

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Thanks!

Preventative Claims

Preventative Claims require minimal to no claim investigation since there are already strict, set limits on how much we will reimburse a policyholder. As such, Claim Advocates don't have to take Claim Investigation factors into account when determining how to proceed. The only additional investigation necessary would be clarification of items or price.

Accident Claims

With Accident claims, the Claim Advocates takes the following into consideration as part of the Claim Investigation:

• Does the claim documentation (e.g., claim media, invoice, etc.) support a true accident?
• Is the accident close to or within the accident waiting period?
• Is the policy greater than seven (7) days old?
• If not, we need the DOL MR
• Is this a recurring condition?
• If the pet has the OG policy, this may require further investigation

Illness Claims

Illness claims have the most complex Claim Investigation factors. Whether an MRR is necessary will depend on:

• The policy length or how long the pet has been enrolled
• The claimed condition
• Specifically looking at "Advanced Health Conditions"
• Whether there are any chronic indicators
• Context from prior claims
• Different waiting periods will apply based on the condition

Click here for a pro tip!