Acute Conditions & Context Clues
Explore more about acute conditions and context clues and how they should be considered during Claim Investigation.
Start
Acute Condition Refresher
Click the headphones for an optional audio read along!
As you may recall from the Claim Investigation courses, acute conditions are an exception to the standard timeline guidelines — meaning we can settle a claim without medical records even if it hasn't been 18 months since the policy effective date. So what actually makes a condition acute? A condition is considered acute when it's highly unlikely it could have:
- Been present before the policy effective date
- Occurred during the applicable waiting period
- Been ongoing since the policy effective date
In practical terms, these are conditions that can't go unmanaged for long, or that aren't likely to be a recurrence or complication of something the pet dealt with in the past. That said, context always matters. You'll still need to take the full picture into account when making your determination.
Reminder
Next
Click the headphones for an optional audio read along!
Guidelines vs. Context
Understanding acute conditions takes both Claim Investigation guidelines and context into consideration, but they're not the same thing, and knowing how they work together makes for an efficient and fair claim review. Some claims are straightforward. The facts are clear, the guidelines apply cleanly, and you can work through it without much gray area. In those cases, the guidelines are your roadmap and you follow them as written. But other claims aren't so cut and dry. Maybe something about the condition, the pet's history, or the claim media gives you pause. That's where context comes in. Context isn't part of the guidelines themselves — it's the lens you apply on top of them. It's your job as a Claim Advocate to weigh what you're seeing and ask yourself: Is there enough here to flex the guidelines, or do the guidelines hold? That said, context isn't an excuse to throw the guidelines out the window. They're your foundation, and that foundation doesn't go away. The goal is to use your knowledge and judgment to figure out when context matters enough to flex them and when it doesn't.
Next
Click the headphones for an optional audio read along!
Context: Why It Matters
Leadership always says every claim should be reviewed on its own merit. And that's not just a catchphrase! It's the whole reason Claim Investigation guidelines are guidelines and not hard rules. Once you have a solid grasp of the foundation, you're better equipped to read between the lines and really examine what's in front of you. When reviewing a claim, the full picture includes:
- How long it's been since the policy effective date
- The condition itself
- Any medical records we have on file
- The age of the pet
- The breed of the pet
- The claim media
- The diagnostics performed and treatment provided
No two claims are exactly alike. That's exactly why understanding both the guidelines and the context around them makes you a stronger Advocate.
Context Matters: "Everyone on my floor is coding!"
Next
Click the headphones for an optional audio read along!
Full Picture Of The Claim
The full picture isn't just a checklist. Each context clue in the claim can tell you something meaningful about whether a condition is likely acute, chronic, or somewhere in between. Some will carry more weight than others depending on the claim, but knowing what to look for in each one is what sharpens your judgment over time. See below for more information on how to utilize each context clue.
Timeline
Breed Of The Pet
Condition
Claim Media
MR On File
Diagnostics & Treatment
Age Of The Pet
Next
Click the headphones for an optional audio read along!
Combining Guidelines & Context
Knowing how to combine guidelines and context is something that takes practice. And honestly, it's not something that can be neatly mapped out in a flowchart or fully captured in a training. As stated previously, no two claims are the same, and that's kind of the point. What it does take is:
- Curiosity: Asking questions and digging into the details
- Big picture thinking: Stepping back to see the full story a claim is telling
- Flexibility: Being open to what the context is showing you
- Resourcefulness: Leaning on your knowledge, your tools, and your team
- Trust: Not overthinking it when the answer is in front of you
No set of examples can cover every situation you'll run into. As you go through the examples in this course, focus on the concepts and the thinking behind each one because that's what will translate to your real-world claims.
Next
Click the headphones for an optional audio read along!
Timeline & Context
Context and acute conditions typically only come into play when a claim date is less than 18 months since the policy effective date. Claims that fall past the 18 month mark will generally follow the guidelines as written since most will be able to proceed without medical records unless there are chronic indicators or the condition is congenital (both of which are their own form of context). For claims under 18 months, there's no magic number that serves as a hard cutoff for when medical records are required assuming the condition is acute. That determination comes down to the individual claim and the context surrounding it. The examples below walk through the same scenario a few times, each with a slight shift in context. As you go through them, you'll notice that small changes in context can change the outcome entirely, BUT it's not entirely dependent on the timeline (with the exception of example 2).
We only received vague discharge instructions (no SOAPs) and claim media was brief with no timeline provided. Invoice is for SQF, metronidazole, probiotics, and 7 days of i/d food. Drag the card to see the next one.
The evidence in the DOL MR and claim media supports that this is an acute onset of diarrhea. Statistically speaking, this dog likely hasn't had diarrhea for 10 months with no claims having been filed. Proceed with the claim without MR and cover it.
We lack evidence that shows that this is a truly acute issue since we don't have DOL MR and the claim media was brief. We should follow the guidelines and collect MR to determine eligibility.Drag the card to see the final card.
ER DOL MR shows 24-hour onset, r/o gastroenteritis. Dog given SQF, metronidazole, probiotics, 7 days of i/d food. Matches with claim media statement. Drag the card to see the next one.
ER DOL MR shows 24-hour onset, r/o gastroenteritis. Dog given SQF, metronidazole, probiotics, 7 days of i/d food. Matches with claim media statement. Drag the card to see the next one.
No additional MR on file. No URCs. No prior claims filed. How can we proceed? Drag the card to see the final card.
No additional MR on file. No URCs. No prior claims filed. How can we proceed? Drag the card to see the next card.
If this example had more context such as a detailed claim media or DOL MR, we could have treated this claim as an acute condition since that would have given us enough evidence to determine that it was an acute onset of diarrhea.
No additional MR on file. No URCs. No prior claims filed. How can we proceed? Drag the card to see the final card.
Has this dog likely had diarrhea for the last 3 months? Probably not. But the risk of diarrhea being pre-existing is a bit higher than the 10 month example. We should follow the guidelines and gather MR to determine coverage.
Example 2: Drag the card to see the next card below it.
Example 3: Drag the card to see the next card below it.
Example 1: Drag the card to see the next card below it.
Mixed breed dog enrolled at 4 months old. Claim is 6 months post policy effective date. Claimed condition: diarrhea. Drag the card to see the next one.
Mixed breed dog enrolled at 4 months old. Claim is 3 months post policy effective date. Claimed condition: diarrhea. Drag the card to see the next one.
Mixed breed dog enrolled at 4 months old. Claim is 10 months post policy effective date. Claimed condition: diarrhea. Drag the card to see the next one.
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Next
FAQ
Click the headphones for an optional audio read along!
Q: If we settle a claim with limited or no medical records and it hasn't been 18 months since the policy effective date, should we mark the MRR as complete? A: No. Only mark an MRR complete with limited or no records if it's been more than 18 months since the policy effective date. Q: If we're not sticking strictly to the guidelines, won't that lead to more subjectivity between Claim Advocates? A: Maybe, if we are not using the claim context well. Everyone does have different clinical backgrounds and this may influence risk tolerance slightly, but we all have the same guidelines and a solid foundation of veterinary knowledge to draw from so variations should be rare and not result in drastically different coverage. Q: What if I just want to stick strictly to the guidelines and not use context? A: We don’t recommend this. The guidelines and the context are meant to help empower you to move through claims with more confidence and less red tape, while creating a consistent customer experience without sacrificing accuracy. If you adhere too harshly to a single line in the sand, you’ll end up slowing yourself down and become ineffective at handling claims due to over requesting information. Give yourself permission to ease into it and check in with your Lead as needed. Just keep challenging yourself to get more comfortable working in the gray zone. Q: What if I cover something that turns out to be pre-existing? I don't want to make the wrong call. A: This happens today sometimes. We don’t expect or ask for 100% QA because sometime mistakes happen. The occasional error vs repetitive poor decision making due missing important medical context or risk assessment skills are two very different situations.
Next
Pep Talk!
Click the headphones for an optional audio read along!
Using context and making decisions without medical records is not something to shy away from. Pet Leadership trusts your expertise — and that trust is not just a formality. You are more than a checklist. You are a skilled claims professional with real veterinary knowledge, and you don't need permission to lean into that. Deciding to cover something based on your judgment isn't just okay. It's the expectation. The ultimate goal is for you to feel empowered to move claims forward efficiently, not bogged down by red tape. And if you're ever unsure, the guidelines are always there to fall back on. And when in serious doubt, get a second opinion from your Lead!
End
Click the headphones for an optional audio read along!
Diagnostics & Treatment: On the diagnostics side, veterinarians generally follow a logical progression, starting with the most straightforward explanation for a pet's symptoms before working toward more complex ones. When the diagnostics performed don't match that progression, it's worth paying attention. For example, a UTI claim 12 months post policy with a UA and culture makes sense for a straightforward infection. Add a cystoscopy to that workup and it raises the question of why a more invasive diagnostic was performed for what's being presented as a simple UTI. Treatment tells a similar story. A 30-day supply of Baytril, probiotics, and prescription GI food on a diarrhea claim 10 months post policy is a lot of firepower for an acute bout of diarrhea, and that length and intensity of treatment should encourage you to gather medical records. A 7-day course of Metronidazole with probiotics and GI food, on the other hand, is far more expected for an acute presentation and would support moving forward without records. Ultimately, when both the diagnostics and treatment make sense for what's being claimed, that corroboration carries real weight in your determination.
Click the headphones for an optional audio read along!
Timeline: The timeline is already a key factor in Claim Investigation, but when it comes to acute conditions and settling claims with limited or no medical records, it carries extra weight. There's a meaningful difference between a three month old policy and a nine month old policy. Simply put, the longer the policy has been active, the lower the risk. Consider this example: an ear infection claimed two days after the illness waiting period ends carries a higher risk that the condition was already present during the waiting period. Without medical records, we can't know for certain. But an ear infection claimed 16 months after the waiting period, with no prior claims for ear infections or allergy-related issues, makes it highly unlikely the condition has been chronic or recurrent. And here's something worth keeping in mind: most policyholders submit every invoice they have. They're not sitting on claims they know aren't eligible, and they're not strategically waiting out a timeline hoping a condition will eventually get covered. That's why we're able to use the claim history and timeline has part of our context clues.
Click the headphones for an optional audio read along!
Age Of The Pet: The age of a pet can tell you a lot about how likely it is that a condition existed before the policy effective date. Certain conditions are more expected at certain life stages. Arthritis and hypothyroidism, for example, are more common in older pets and can be managed at home for a while before they significantly affect quality of life. In younger pets, we tend to see more self-limiting conditions. Because of that, the condition and the age of the pet will almost always need to be considered together. For example, if a pet was enrolled at 8 weeks of age, the chances of most conditions having been present or symptomatic before enrollment or during the 14-day waiting period are pretty low, with the exception of parasites and congenital conditions. So if we receive a claim for a dog that started vomiting 36 hours before the claim date, it's been 8 months since the policy effective date, and there are no prior GI claims, we can proceed without medical records. However, if that same dog enrolled at 8 weeks has a first claim 8 months after the policy effective date for a shunt workup (e.g. CT scan, ultrasound, etc.), that's a different story. A portosystemic shunt is congenital and symptoms can appear early. Medical records should be obtained in that scenario.
Click the headphones for an optional audio read along!
Condition: Just like the timeline, the condition itself is already a central factor in Claim Investigation, and this is where your veterinary knowledge really comes into play. Acute conditions are those highly unlikely to have gone untreated since before the policy effective date. A good example: a dog diagnosed with pneumonia, presenting with a harsh cough, increased respiratory rate, and lethargy, 11 months into the policy. It's highly unlikely that dog has had untreated pneumonia for 11 months, and equally unlikely the policyholder wouldn't have submitted a claim if they'd noticed symptoms earlier or if there had been a precipitating illness that could have caused the pneumonia. So we could proceed with covering the pneumonia without collecting medical records. But the same logic doesn't always apply across the board. Take a cruciate ligament tear. We can reasonably assume a dog hasn't been walking around on an untreated torn cruciate for 11 months, but cruciate tears are bilateral conditions. And not every dog, especially younger ones, will have follow-up claims for joint supplements, such as Adequan or Rimadyl after surgical correction. Without that paper trail, we don't have enough to confidently rule out a pre-existing condition, which means medical records are needed to proceed. However, always remember to take other context into account like the age of the pet at the time of enrollment. If they were enrolled very young (less than 6 months), then the chances that they had a cruciate tear pre-policy are extremely low. So it's not always a hard and fast rule!
Click the headphones for an optional audio read along!
Claim Media: Claim media is a useful context clue, but it should always be taken with a grain of salt. Policyholders often have little to no medical knowledge, which means they may describe something inaccurately simply because they don't fully understand what's happening with their pet. A classic example is a policyholder attributing a cruciate tear or patellar luxation to an accident when that's not typically how those conditions present. That doesn't mean they're being dishonest — they just don't know what we know. What claim media is most useful for is two things: the timeline (when did this start?) and the at-home presentation (what did the policyholder actually observe?). Those two pieces of information are what you'll weigh alongside your other context clues. The way a policyholder describes the timeline can make a significant difference in how you proceed. "He's been having some diarrhea for a little while," leaves too much room for interpretation to comfortably move forward without more information. "He's been having diarrhea for the last two days," gives you a concrete timeframe to work with and makes a stronger case for proceeding as an acute condition. The difference between those two statements might seem small, but it can meaningfully change the determination.
Click the headphones for an optional audio read along!
Medical Records On File: If medical records are already on file, always review them before making a determination. If they're complete, have an MRR performed. If they're incomplete but the condition appears acute, review what you do have and ask yourself whether it supports proceeding with the claim or if there are any red flags that would warrant requesting additional records. Here's an example: a dog enrolled for 13 months has a claim for seizures. The date of loss records state, "Just had seizure, no history of seizures," and the claim history and URCs back that up. That's enough to consider it an acute onset and proceed without prior medical records. But swap that 13 months for 3 months, and the timeline shifts the risk enough that medical records should be obtained before moving forward. This is also a good illustration of why no single context clue can drive a determination on its own. The medical records supported the decision in the first scenario, but without a reasonable timeline, they wouldn't have been enough. Every element of the full picture works together.
Click the headphones for an optional audio read along!
Breed Of The Pet: Certain breeds carry well-known predispositions to specific conditions, and that context is worth factoring in. Miniature Schnauzers, for example, are highly susceptible to pancreatitis. If we receive a pancreatitis claim for a Schnauzer, the breed alone doesn't tell us everything, but combined with age and claim history, it can shift the risk assessment. An older Schnauzer carries a higher risk of having had prior bouts than a younger one. Breed can also raise flags when the claimed condition doesn't quite add up. If we receive a claim filed as a soft tissue injury for a 4 year old German Shepherd 16 months post policy effective date, and the date of loss records note a pain reaction on extension of the hips with rule outs including hip dysplasia, that's worth a closer look. German Shepherds have a well-documented predisposition to hip dysplasia, and that combined with the clinical presentation is enough reason to pursue additional records before proceeding. Important: Breed is one area where your veterinary background gives you a real advantage. That said, breed awareness shouldn't turn into breed assumptions. As in the example above, seeing a Schnauzer on a pancreatitis claim doesn't automatically mean records are required. It means breed is one more piece of information to weigh alongside everything else.
Click the headphones for an optional audio read along!
Reminder:
If you settle a claim with limited or no medical records and it hasn't been 18 months since the policy effective date, do not mark the MRR as complete. This should only be done if it's been more than 18 months since the policy effective date. If complete medical records are already on file, an MRR should be performed regardless of whether the condition is acute or not. Just don't go requesting additional records if what you have is sufficient to make a determination.
Acute Conditions & Context Clues
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Transcript
Acute Conditions & Context Clues
Explore more about acute conditions and context clues and how they should be considered during Claim Investigation.
Start
Acute Condition Refresher
Click the headphones for an optional audio read along!
As you may recall from the Claim Investigation courses, acute conditions are an exception to the standard timeline guidelines — meaning we can settle a claim without medical records even if it hasn't been 18 months since the policy effective date. So what actually makes a condition acute? A condition is considered acute when it's highly unlikely it could have:
- Been present before the policy effective date
- Occurred during the applicable waiting period
- Been ongoing since the policy effective date
In practical terms, these are conditions that can't go unmanaged for long, or that aren't likely to be a recurrence or complication of something the pet dealt with in the past. That said, context always matters. You'll still need to take the full picture into account when making your determination.Reminder
Next
Click the headphones for an optional audio read along!
Guidelines vs. Context
Understanding acute conditions takes both Claim Investigation guidelines and context into consideration, but they're not the same thing, and knowing how they work together makes for an efficient and fair claim review. Some claims are straightforward. The facts are clear, the guidelines apply cleanly, and you can work through it without much gray area. In those cases, the guidelines are your roadmap and you follow them as written. But other claims aren't so cut and dry. Maybe something about the condition, the pet's history, or the claim media gives you pause. That's where context comes in. Context isn't part of the guidelines themselves — it's the lens you apply on top of them. It's your job as a Claim Advocate to weigh what you're seeing and ask yourself: Is there enough here to flex the guidelines, or do the guidelines hold? That said, context isn't an excuse to throw the guidelines out the window. They're your foundation, and that foundation doesn't go away. The goal is to use your knowledge and judgment to figure out when context matters enough to flex them and when it doesn't.
Next
Click the headphones for an optional audio read along!
Context: Why It Matters
Leadership always says every claim should be reviewed on its own merit. And that's not just a catchphrase! It's the whole reason Claim Investigation guidelines are guidelines and not hard rules. Once you have a solid grasp of the foundation, you're better equipped to read between the lines and really examine what's in front of you. When reviewing a claim, the full picture includes:
- How long it's been since the policy effective date
- The condition itself
- Any medical records we have on file
- The age of the pet
- The breed of the pet
- The claim media
- The diagnostics performed and treatment provided
No two claims are exactly alike. That's exactly why understanding both the guidelines and the context around them makes you a stronger Advocate.Context Matters: "Everyone on my floor is coding!"
Next
Click the headphones for an optional audio read along!
Full Picture Of The Claim
The full picture isn't just a checklist. Each context clue in the claim can tell you something meaningful about whether a condition is likely acute, chronic, or somewhere in between. Some will carry more weight than others depending on the claim, but knowing what to look for in each one is what sharpens your judgment over time. See below for more information on how to utilize each context clue.
Timeline
Breed Of The Pet
Condition
Claim Media
MR On File
Diagnostics & Treatment
Age Of The Pet
Next
Click the headphones for an optional audio read along!
Combining Guidelines & Context
Knowing how to combine guidelines and context is something that takes practice. And honestly, it's not something that can be neatly mapped out in a flowchart or fully captured in a training. As stated previously, no two claims are the same, and that's kind of the point. What it does take is:
- Curiosity: Asking questions and digging into the details
- Big picture thinking: Stepping back to see the full story a claim is telling
- Flexibility: Being open to what the context is showing you
- Resourcefulness: Leaning on your knowledge, your tools, and your team
- Trust: Not overthinking it when the answer is in front of you
No set of examples can cover every situation you'll run into. As you go through the examples in this course, focus on the concepts and the thinking behind each one because that's what will translate to your real-world claims.Next
Click the headphones for an optional audio read along!
Timeline & Context
Context and acute conditions typically only come into play when a claim date is less than 18 months since the policy effective date. Claims that fall past the 18 month mark will generally follow the guidelines as written since most will be able to proceed without medical records unless there are chronic indicators or the condition is congenital (both of which are their own form of context). For claims under 18 months, there's no magic number that serves as a hard cutoff for when medical records are required assuming the condition is acute. That determination comes down to the individual claim and the context surrounding it. The examples below walk through the same scenario a few times, each with a slight shift in context. As you go through them, you'll notice that small changes in context can change the outcome entirely, BUT it's not entirely dependent on the timeline (with the exception of example 2).
We only received vague discharge instructions (no SOAPs) and claim media was brief with no timeline provided. Invoice is for SQF, metronidazole, probiotics, and 7 days of i/d food. Drag the card to see the next one.
The evidence in the DOL MR and claim media supports that this is an acute onset of diarrhea. Statistically speaking, this dog likely hasn't had diarrhea for 10 months with no claims having been filed. Proceed with the claim without MR and cover it.
We lack evidence that shows that this is a truly acute issue since we don't have DOL MR and the claim media was brief. We should follow the guidelines and collect MR to determine eligibility.Drag the card to see the final card.
ER DOL MR shows 24-hour onset, r/o gastroenteritis. Dog given SQF, metronidazole, probiotics, 7 days of i/d food. Matches with claim media statement. Drag the card to see the next one.
ER DOL MR shows 24-hour onset, r/o gastroenteritis. Dog given SQF, metronidazole, probiotics, 7 days of i/d food. Matches with claim media statement. Drag the card to see the next one.
No additional MR on file. No URCs. No prior claims filed. How can we proceed? Drag the card to see the final card.
No additional MR on file. No URCs. No prior claims filed. How can we proceed? Drag the card to see the next card.
If this example had more context such as a detailed claim media or DOL MR, we could have treated this claim as an acute condition since that would have given us enough evidence to determine that it was an acute onset of diarrhea.
No additional MR on file. No URCs. No prior claims filed. How can we proceed? Drag the card to see the final card.
Has this dog likely had diarrhea for the last 3 months? Probably not. But the risk of diarrhea being pre-existing is a bit higher than the 10 month example. We should follow the guidelines and gather MR to determine coverage.
Example 2: Drag the card to see the next card below it.
Example 3: Drag the card to see the next card below it.
Example 1: Drag the card to see the next card below it.
Mixed breed dog enrolled at 4 months old. Claim is 6 months post policy effective date. Claimed condition: diarrhea. Drag the card to see the next one.
Mixed breed dog enrolled at 4 months old. Claim is 3 months post policy effective date. Claimed condition: diarrhea. Drag the card to see the next one.
Mixed breed dog enrolled at 4 months old. Claim is 10 months post policy effective date. Claimed condition: diarrhea. Drag the card to see the next one.
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Next
FAQ
Click the headphones for an optional audio read along!
Q: If we settle a claim with limited or no medical records and it hasn't been 18 months since the policy effective date, should we mark the MRR as complete? A: No. Only mark an MRR complete with limited or no records if it's been more than 18 months since the policy effective date. Q: If we're not sticking strictly to the guidelines, won't that lead to more subjectivity between Claim Advocates? A: Maybe, if we are not using the claim context well. Everyone does have different clinical backgrounds and this may influence risk tolerance slightly, but we all have the same guidelines and a solid foundation of veterinary knowledge to draw from so variations should be rare and not result in drastically different coverage. Q: What if I just want to stick strictly to the guidelines and not use context? A: We don’t recommend this. The guidelines and the context are meant to help empower you to move through claims with more confidence and less red tape, while creating a consistent customer experience without sacrificing accuracy. If you adhere too harshly to a single line in the sand, you’ll end up slowing yourself down and become ineffective at handling claims due to over requesting information. Give yourself permission to ease into it and check in with your Lead as needed. Just keep challenging yourself to get more comfortable working in the gray zone. Q: What if I cover something that turns out to be pre-existing? I don't want to make the wrong call. A: This happens today sometimes. We don’t expect or ask for 100% QA because sometime mistakes happen. The occasional error vs repetitive poor decision making due missing important medical context or risk assessment skills are two very different situations.
Next
Pep Talk!
Click the headphones for an optional audio read along!
Using context and making decisions without medical records is not something to shy away from. Pet Leadership trusts your expertise — and that trust is not just a formality. You are more than a checklist. You are a skilled claims professional with real veterinary knowledge, and you don't need permission to lean into that. Deciding to cover something based on your judgment isn't just okay. It's the expectation. The ultimate goal is for you to feel empowered to move claims forward efficiently, not bogged down by red tape. And if you're ever unsure, the guidelines are always there to fall back on. And when in serious doubt, get a second opinion from your Lead!
End
Click the headphones for an optional audio read along!
Diagnostics & Treatment: On the diagnostics side, veterinarians generally follow a logical progression, starting with the most straightforward explanation for a pet's symptoms before working toward more complex ones. When the diagnostics performed don't match that progression, it's worth paying attention. For example, a UTI claim 12 months post policy with a UA and culture makes sense for a straightforward infection. Add a cystoscopy to that workup and it raises the question of why a more invasive diagnostic was performed for what's being presented as a simple UTI. Treatment tells a similar story. A 30-day supply of Baytril, probiotics, and prescription GI food on a diarrhea claim 10 months post policy is a lot of firepower for an acute bout of diarrhea, and that length and intensity of treatment should encourage you to gather medical records. A 7-day course of Metronidazole with probiotics and GI food, on the other hand, is far more expected for an acute presentation and would support moving forward without records. Ultimately, when both the diagnostics and treatment make sense for what's being claimed, that corroboration carries real weight in your determination.
Click the headphones for an optional audio read along!
Timeline: The timeline is already a key factor in Claim Investigation, but when it comes to acute conditions and settling claims with limited or no medical records, it carries extra weight. There's a meaningful difference between a three month old policy and a nine month old policy. Simply put, the longer the policy has been active, the lower the risk. Consider this example: an ear infection claimed two days after the illness waiting period ends carries a higher risk that the condition was already present during the waiting period. Without medical records, we can't know for certain. But an ear infection claimed 16 months after the waiting period, with no prior claims for ear infections or allergy-related issues, makes it highly unlikely the condition has been chronic or recurrent. And here's something worth keeping in mind: most policyholders submit every invoice they have. They're not sitting on claims they know aren't eligible, and they're not strategically waiting out a timeline hoping a condition will eventually get covered. That's why we're able to use the claim history and timeline has part of our context clues.
Click the headphones for an optional audio read along!
Age Of The Pet: The age of a pet can tell you a lot about how likely it is that a condition existed before the policy effective date. Certain conditions are more expected at certain life stages. Arthritis and hypothyroidism, for example, are more common in older pets and can be managed at home for a while before they significantly affect quality of life. In younger pets, we tend to see more self-limiting conditions. Because of that, the condition and the age of the pet will almost always need to be considered together. For example, if a pet was enrolled at 8 weeks of age, the chances of most conditions having been present or symptomatic before enrollment or during the 14-day waiting period are pretty low, with the exception of parasites and congenital conditions. So if we receive a claim for a dog that started vomiting 36 hours before the claim date, it's been 8 months since the policy effective date, and there are no prior GI claims, we can proceed without medical records. However, if that same dog enrolled at 8 weeks has a first claim 8 months after the policy effective date for a shunt workup (e.g. CT scan, ultrasound, etc.), that's a different story. A portosystemic shunt is congenital and symptoms can appear early. Medical records should be obtained in that scenario.
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Condition: Just like the timeline, the condition itself is already a central factor in Claim Investigation, and this is where your veterinary knowledge really comes into play. Acute conditions are those highly unlikely to have gone untreated since before the policy effective date. A good example: a dog diagnosed with pneumonia, presenting with a harsh cough, increased respiratory rate, and lethargy, 11 months into the policy. It's highly unlikely that dog has had untreated pneumonia for 11 months, and equally unlikely the policyholder wouldn't have submitted a claim if they'd noticed symptoms earlier or if there had been a precipitating illness that could have caused the pneumonia. So we could proceed with covering the pneumonia without collecting medical records. But the same logic doesn't always apply across the board. Take a cruciate ligament tear. We can reasonably assume a dog hasn't been walking around on an untreated torn cruciate for 11 months, but cruciate tears are bilateral conditions. And not every dog, especially younger ones, will have follow-up claims for joint supplements, such as Adequan or Rimadyl after surgical correction. Without that paper trail, we don't have enough to confidently rule out a pre-existing condition, which means medical records are needed to proceed. However, always remember to take other context into account like the age of the pet at the time of enrollment. If they were enrolled very young (less than 6 months), then the chances that they had a cruciate tear pre-policy are extremely low. So it's not always a hard and fast rule!
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Claim Media: Claim media is a useful context clue, but it should always be taken with a grain of salt. Policyholders often have little to no medical knowledge, which means they may describe something inaccurately simply because they don't fully understand what's happening with their pet. A classic example is a policyholder attributing a cruciate tear or patellar luxation to an accident when that's not typically how those conditions present. That doesn't mean they're being dishonest — they just don't know what we know. What claim media is most useful for is two things: the timeline (when did this start?) and the at-home presentation (what did the policyholder actually observe?). Those two pieces of information are what you'll weigh alongside your other context clues. The way a policyholder describes the timeline can make a significant difference in how you proceed. "He's been having some diarrhea for a little while," leaves too much room for interpretation to comfortably move forward without more information. "He's been having diarrhea for the last two days," gives you a concrete timeframe to work with and makes a stronger case for proceeding as an acute condition. The difference between those two statements might seem small, but it can meaningfully change the determination.
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Medical Records On File: If medical records are already on file, always review them before making a determination. If they're complete, have an MRR performed. If they're incomplete but the condition appears acute, review what you do have and ask yourself whether it supports proceeding with the claim or if there are any red flags that would warrant requesting additional records. Here's an example: a dog enrolled for 13 months has a claim for seizures. The date of loss records state, "Just had seizure, no history of seizures," and the claim history and URCs back that up. That's enough to consider it an acute onset and proceed without prior medical records. But swap that 13 months for 3 months, and the timeline shifts the risk enough that medical records should be obtained before moving forward. This is also a good illustration of why no single context clue can drive a determination on its own. The medical records supported the decision in the first scenario, but without a reasonable timeline, they wouldn't have been enough. Every element of the full picture works together.
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Breed Of The Pet: Certain breeds carry well-known predispositions to specific conditions, and that context is worth factoring in. Miniature Schnauzers, for example, are highly susceptible to pancreatitis. If we receive a pancreatitis claim for a Schnauzer, the breed alone doesn't tell us everything, but combined with age and claim history, it can shift the risk assessment. An older Schnauzer carries a higher risk of having had prior bouts than a younger one. Breed can also raise flags when the claimed condition doesn't quite add up. If we receive a claim filed as a soft tissue injury for a 4 year old German Shepherd 16 months post policy effective date, and the date of loss records note a pain reaction on extension of the hips with rule outs including hip dysplasia, that's worth a closer look. German Shepherds have a well-documented predisposition to hip dysplasia, and that combined with the clinical presentation is enough reason to pursue additional records before proceeding. Important: Breed is one area where your veterinary background gives you a real advantage. That said, breed awareness shouldn't turn into breed assumptions. As in the example above, seeing a Schnauzer on a pancreatitis claim doesn't automatically mean records are required. It means breed is one more piece of information to weigh alongside everything else.
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Reminder:
If you settle a claim with limited or no medical records and it hasn't been 18 months since the policy effective date, do not mark the MRR as complete. This should only be done if it's been more than 18 months since the policy effective date. If complete medical records are already on file, an MRR should be performed regardless of whether the condition is acute or not. Just don't go requesting additional records if what you have is sufficient to make a determination.