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.
Next
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
Next
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!
Next
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!
Next
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!
Next
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.
Scenario #1 - Remi
Lemonade
Created on September 3, 2025
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Transcript
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.
Next
Claim Overview
Next
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!
Next
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!
Next
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!
Next
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.