Scenario #4 - Lucy

Scenario #4

Lucy

Start

TL;DR + Claim Media

Both Lucy and Grover have been scratching consistently on their ears and shoulders and chewing at their feet.

Claim Lifecycle

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Claim Overview

• Policy Information:
• Policy Started On: 3/4/2025
• Illness Eligible From: 3/18/2025
• Orthopedic Coverage Eligible From: 4/3/2025
• Policy Type: Cian, Vet Visit Fee add-on, Prev+ add-on
• Claim Information:
• Claim Filed On: 3/25/2025
• Occurrence Date Per PH: 3/23/2025
• Vet Visit Date Per PH: 3/24/2025
• Claimed Condition: Skin Allergies

• 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, vet information omitted for space):

Invoice looks altered because it was cut from 2 pages to 1 for training purposes. So don't worry about possible misrepresentation! :)

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!

End

Do we need MR: Yes Do we need an MRR: Yes Why?: This claim was filed less than a week after the IWP ended. Additionally, it's an AHC (allergies). Due to the time factor and the fact that it's an AHC, we need to gather MR to perform an MRR to determine coverage.