Claim Advo CE - Scenario #8 - Gia

Scenario #8

Gia

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TL;DR + Claim Media

Gia began having a seizure on Saturday night. It was a grand mal seizure lasted about 2 minutes or so. It was the first seizure she ever had. We went to an overnight emergency vet. She had stopped seizing by the time that we got there. They ran blood work and other tests. Radiographs and urine test and wanted to see if there was maybe some toxin she ingested. She didn't find any and I think we're all hoping it was a one-off. She was doing fine when we left the emergency vet, we went back home. A few hours later she was seizing. The emergency vet gave me, a nasal spray to stop the seizure. It didn't really work. So they transferred us to a neurologist to do an MRI and a spinal tap. They didn't find any tumors or anything like that, so she was diagnosed with epilepsy and started on phenobarbital. She's been on phenobarbital for the last few days. She hasn't had another seizure. They also have burned her neck very badly as well.

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Claim Overview + Additional Info

• Policy Information:
• Policy Started On: 8/23/2023
• Illness Eligible From: 9/6/2023
• Cruciate Coverage Eligible From: 2/23/2024
• Policy Type: OG, Vet Visit Fee add-on
• Claim Information:
• Claim Filed On: 3/25/2025
• Occurrence Date Per PH: 3/22/2025
• Vet Visit Date Per PH: 3/23/2025
• Claimed Condition: Epilepsy

• MRR?:
• MRR previously completed
• Pre-Existing Conditions?:
• Gastritis/Vomiting, Diarrhea, Abrasion

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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 information? Why or why not? Do we need additional medical records? Why or why not? Think about it before proceeding to the following page!

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Claim Investigation Determination

Done thinking? Click on the image below to see how you should proceed with this claim!

Do we need additional medical records?

Do we need additional information?

Defend your reasoning!

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Hypothetical Thought

Bonus question! If the pet had NOT had an MRR performed previously, would we need one? Think about it and check your answer below when you feel confident of how we would proceed. Policy/claim info provided for a refresher.

• Policy Information:
• Policy Started On: 8/23/2023
• Illness Eligible From: 9/6/2023
• Cruciate Coverage Eligible From: 2/23/2024
• Policy Type: OG, Vet Visit Fee add-on
• Claim Information:
• Claim Filed On: 3/25/2025
• Occurrence Date Per PH: 3/22/2025
• Vet Visit Date Per PH: 3/23/2025
• Claimed Condition: Epilepsy

• MRR?:
• MRR previously completed
• Pre-Existing Conditions?:
• Gastritis/Vomiting, Diarrhea, Abrasion

Reveal Answer!

End

MRR Needed?: No Why?: Per Claim Investigation guidelines, we only need an MRR if the claim is between 100 to 364 days and the claimed condition is an AHC. Past 365 days, we're looking only for chronic indicators. Since the claim media stated that she'd never had a seizure previously and there was no claim history suggesting that the pet had chronic epilepsy, we can settle the claim without an MRR.

Do we need MR: No Do we need additional information: Yes, we need the EOBs from Metlife Why?: The prior insurance question was toggled to 'Yes.' We need to either confirm that the pet was canceled or gather the EOBs from Metlife since we are considered a secondary insurer. As far as MR, we don't need additional MR to justify covering the epilepsy. An MRR was previously performed and we know that the pet had no pre-existing neurologic issues. So even though epilepsy is an AHC, we don't need it in this circumstance.