by roybendor » Tue Oct 27, 2009 04:18 pm
Insurance policy is for my dog. Insurer is ASPCA Pet Insurance. My dog is displaying strange behaviors and so we took her to the vet who performed an MRI (which cost over $2,000). The MRI revealed a growth at the base of her skull, which is common in her breed (~95% of cavaliers have this) and which can cause problems. However, my dog does not show symptoms of this problem. Her behaviors do not appear to be connected to this illness or respond to treatment for this illness. The doctor has concluded (as have I) that the growth is not related to her problem. The insurance company claims that it's a congenital or hereditary disease so it's not covered. The statement is ludicruous because we don't even know what IT is, so how can they say it's congenital. The argument is the equivalent to me breaking my foot playing football, having the doctor x-ray my foot and seeing, aside from the break, an abnormality in my foot (that 95% of humans have) and the insurance company saying therefore we're not covering your broken foot.
Posted: Tue Oct 27, 2009 07:39 pm Post Subject:
Based up on your story, I am pretty sure there is more to it.
Posted: Tue Oct 27, 2009 09:06 pm Post Subject:
You're not clear on what they are denying... the problem of the strange behavior or the growth.
Posted: Tue Oct 27, 2009 11:12 pm Post Subject:
The statement is ludicruous because we don't even know what IT is, so how can they say it's congenital
Well, if NO BODY (including the vet) knows what it is, then they cannot 100% say that it is NOT congentital..how can you expect them to pay this without a diagnosis, that you yourself admit to not having...Posted: Wed Nov 11, 2009 03:02 pm Post Subject:
In response to Lori: "how can you expect them to pay this without a diagnosis, that you yourself admit to not having..."
My policy does not say "we do not cover incomplete diagnoses." It says that it does not cover "congenital or hereditary" diseases. They are responsible for paying out any medical expenses legitimately incurred in diagnosis or treatment of my covered pet unless they can exclude it for one of the outlined provisions. So I don't have to prove what it is, they have to.
In response to trench and tcope:
They are denying the claim for the MRI and doctor's visit.
Because the malformation in her head (which is present in 95% of her breed) is congenital or hereditary, and because it was discovered with the MRI they are denying the claim for the MRI and the visit.
They sent me a letter saying that the malformation causes all kinds of diseases, that the vet in her report noted that she couldn't rule it out, and that my dog's behavior could be the result of that. However all the diseases they mention have clear associated symptoms, none of which my dog is demonstrating, and my dog's behavior isn't a symptom of those diseases. However, it is theoretically possible...
Again, this seems totally illogical to me.
Posted: Wed Nov 11, 2009 03:58 pm Post Subject:
It says that it does not cover "congenital or hereditary" diseases. They are responsible for paying out any medical expenses legitimately incurred in diagnosis or treatment of my covered pet unless they can exclude it for one of the outlined provisions.
You are incorrect. The policy offers coverage for certain things. At this time you've not provided any information (a diagnosis) to show that the treatment was for a covered item. It's the insured's responsibility to to provide information to support their claim. The claim of "I don't know what the illness is" does not shift the burden of that proof of coverage to the insurance company. Using the same information, how can you say that this is a covered illness? You can't.But here is the important part:
They are denying the claim for the MRI and doctor's visit.
andThe MRI revealed a growth at the base of her skull, which is common in her breed (~95% of cavaliers have this) and which can cause problems. However, my dog does not show symptoms of this problem. Her behaviors do not appear to be connected to this illness or respond to treatment for this illness. The doctor has concluded (as have I) that the growth is not related to her problem.
So the only issue is that they are not covering the MRI and doctors visit? Are you agreeing that the growth is congenital or hereditary? This statement would seem to indicate this:which is present in 95% of her breed
Posted: Thu Nov 12, 2009 12:36 am Post Subject:
So I don't have to prove what it is, they have to
I'm sorry but your are incorrect, you have to prove (your claim and that) it is NOT a"congenital or hereditary" diseases
It is ALWAYS the insured (or claimants) burden to PROVE their claim.
Posted: Thu Nov 12, 2009 02:07 am Post Subject:
Question Lori: If this is the case, then couldn't they simply claim that any and all illnesses (other than broken bones etc) MAY be related to this growth and therefore decline to cover anything?
Seems like a pretty good escape clause for them if that so and more or less renders the policy worthless, no?
Posted: Thu Nov 12, 2009 11:27 am Post Subject:
then couldn't they simply claim that any and all illnesses (other than broken bones etc) MAY be related to this growth and therefore decline to cover anything?
It is the case, and I suppose...but it shouldn't be that difficult to determine it either is or is not congenital and/or hereditary.Seems like a pretty good escape clause for them if that so and more or less renders the policy worthless, no?
All insurance policys (that I've ever read) give you coverage in one area, and take the majority of that away in another area (exclusions)..I'm having a hard time understanding why it's so hard to say if it hereditary or not?Posted: Thu Nov 12, 2009 08:15 pm Post Subject:
the issue isn't whether the growth is hereditary or not, it's pretty much established that it is - it's whether the growth and the behaviour or problems are related.
There is a growth, and issues relating to that wouldn't be covered as it's a congenital/hereditary issue, but there is nothing to say that the problems the dog is experiencing are realted to that growth or not other than conjecture.
In fact treating the growth seems to have no effect on the issue at hand one way or another, which suggests that it is not related, or the cause of the problem.
My point was that with a "growth" the possible symptoms associated with it would include just about anything. The insurer could claim that almost any illness or symptoms COULD be related to the growth, however unlikely, and therefore avoid cover, making the policy next to useless.
Posted: Fri Nov 13, 2009 11:19 am Post Subject:
Ok, I get your point...but my point is, unless and until you have a diagnosis for the issue at hand and that diagnosis is NOT a congenital or hereditary disease that carrier isn't going to pay a dime.
Again, you are required to prove your loss, and you cannot prove it's not genetic.
I frankly don't understand why or how a vet can't give you a diagnosis. :? :?
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