Scenario #1 - Remi

Scenario #1

Remi

Start

TL;DR + Claim Media

I noticed Remy started to have really loose stools and she I noticed Remy started to have really loose stools and she would eat her food and then immediately go to the bathroom and it would come out loose for the first few hours of the day. And so we took her into the vet because we started noticing blood in her stool and would eat her food and then immediately go to the bathroom and it would come out loose for the first few hours of the day. Then the vet said that she had stress colitis. Then the vet said that she had stress colitis.

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Claim Overview

• Policy Information:
• Policy Started On: 12/30/2024
• Illness Eligible From: 01/13/2025
• Orthopedic Coverage Eligible From: 01/29/2025
• Policy Type: Cian, no add-ons
• Claim Information:
• Claim Filed On: 01/17/2025
• Occurrence Date Per PH: 01/15/2025
• Vet Visit Date Per PH: 01/15/2025
• Claimed Condition: Colitis

• MRR?:
• MRR is not completed at this time
• Pre-Existing Conditions?:
• No pre-existing conditions had been identified at the time the claim was filed

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Invoice

The submitted invoice is below (client information intentionally omitted):

How would you proceed with this claim with the information provided to you? Do we need additional medical records? Why or why not? Discuss before proceeding to the following page!

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Claim Investigation Determination

Click on the image below to see how a Claim Advocate would proceed with this claim!

Do we need additional medical records?

Do we need an MRR?

Defend your reasoning!

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Claim Determination

How would you handle the rest of this claim?

What would we tag this condition as?

• Pre-existing
• Illness waiting period
• Ortho Waiting Period
• Cruciate Waiting Period
• Behavioral
• Dental
• Bilateral
• UW

Reveal Answer!

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Claim Determination

What would be the most appropriate way to reject these items?

• Pre-existing
• Illness waiting period
• No loss incurred
• No Vet Visit Fees
• No Preventative coverage

Reveal Answer!

End

The tag should be: Pre-Existing Why?: The vet visit date was prior to the policy effective date. As such, the colitis would be considered pre-existing since it occurred prior to the policy effective date.

The tag should be: Pre-Existing Why?: All charges were prior to the policy effective date. As such, they're all considered pre-existing. Even the exam fee. It wasn't covered because the pet didn't have the Vet Visit add-on - it wasn't covered because the visit and condition are pre-existing.

Do we need MR: No Do we need an MRR: No Why?: The vet visit date was 12/23/2024, not 1/15/2025 as the policyholder entered during the claim submission. As such, the vet visit date was prior to the policy effective date. With Claim Investigation guidelines, we don't need nor want to delay claim denials with gathering medical records or performing an MRR when we know with certainty that the claim isn't eligible for coverage.