Please read below for important information to help you understand our coverage. Keep in mind, we will not reduce coverage or increase premium due to claims history.
We use certain terms in our policy documents and want to make sure you understand how they are used. Following are some common DEFINITIONS:
- Congenital anomaly or disorder – means a Condition that is present from birth, whether inherited or caused by the environment, which may cause or otherwise contribute to Illness or disease.
- Hereditary disorder – means an abnormality that is genetically transmitted from parent to offspring and may cause Illness or disease.
- Pet insurance – means an individual or group insurance policy that provides coverage for Veterinary expenses.
- Pre-existing condition – means any Condition for which a Veterinarian provided medical advice, the Pet received Treatment for, or the Pet displayed signs or Symptoms consistent with the stated Condition prior to the Effective Date of a Pet insurance policy or during any waiting period.
- Usual and Customary Costs – Typical fees that Veterinarians in the same territory charge based on proprietary data and available industry information as determined by the process outlined under What Is Covered.
- Veterinarian – means an individual who holds a valid license to practice Veterinary medicine from the Veterinary Medical Board pursuant to Chapter 11 (commencing with Section 4800) of Division 2 of the Business and Professions Code or other appropriate licensing entity in the jurisdiction in which he or she practices.
- Waiting Period – means the period of time specified in a Pet Insurance Policy that is required to transpire before some or all of the coverage in the policy can begin.
Coverage for the following conditions may be EXCLUDED depending upon the plan chosen.
- Pre – existing condition: Pre-existing conditions are not covered by our plans. However, a condition will no longer be considered preexisting if 180 days have passed since the pet’s condition was cured and free from treatment and symptoms.
- Hereditary disorder and Congenital anomaly or disorder: Hereditary disorders and Congenital anomalies or disorders are excluded from coverage on the Level 1 and Level 2 plans. A list of these conditions is available here and is included with the policy documents. These disorders are covered by our Level 3 plan up to the applicable incident and lifetime limits.
- Chronic conditions and ongoing conditions: Chronic conditions are those that can be treated or managed, but not cured. An ongoing condition is any condition that requires treatment in multiple policy periods. Our base plans provide coverage for chronic and ongoing conditions during the plan year in which the symptoms first appear. If eligible, the Continuing Care Endorsement provides coverage for conditions that span to another plan year. The Continuing Care Endorsement has separate deductible and incident/lifetime limits.
Other exclusions may apply. Please refer to the exclusions section of the policy (What Is Not Covered) for more information. Please continue reading for information on Waiting Periods, Claims, Deductibles, Co-insurance and Other Policy Limits.
There are WAITING PERIODS that apply before certain coverages are effective. On Levels 2, and 3, a 30-day illness waiting period applies to the first policy period. On Level 3, conditions that appear on the Hereditary, Genetic, or Congenital List are subject to a 180 day waiting period. Diagnosis and treatment for ligament and knee conditions are subject to a 12 month waiting period on all policies. Conditions that occur during a waiting period are considered pre-existing.
DETERMINATION OF CLAIM PAYMENTS
Our accident and illness coverage provides reimbursement for Usual and Customary costs for expenses incurred during the Policy Period that are eligible for coverage under Your policy, referred to as Covered Expenses. After subtracting the deductible amount shown on the declarations page from Covered Expenses and applying Your Co-insurance listed on the declarations page, We will pay Our portion of the Covered Expenses up to any applicable maximums. There are maximum amounts specified on the declarations page for the Incident Limit that applies to each eligible Incident. Please refer to the declarations page for other applicable coverage.
Usual and Customary Basis: Usual and Customary costs are determined by using proprietary and industry data. We use proprietary data to group zip codes into territories based on the veterinary fees charged there. Excluding outliers, the mean of the charges falling with the third quartile are deemed Usual and Customary for each territory. Publicly available industry data is used to validate the results of Our calculations.
Wellness benefits are paid according to the schedule of benefits provided with the policy, if applicable.
We offer a choice of annual deductible options. The annual deductible applies to each policy period. We subtract that deductible amount from the covered expenses before calculating your co-insurance.
We offer a choice of co-insurance options. After the deductible is met, you are responsible for your portion of the covered expenses in addition to any amounts not covered by the policy. We then pay our portion of the covered expenses subject to any applicable plan limits.
|Plan Levels||Base Policy||Continuing Care Endorsement(covers chronic and ongoing conditions)||Congenital and Hereditary Care Endorsement(covers Hereditary disorders and Congenital anomaly or disorders included on the Hereditary, Genetic, and Congenital List)|
|Annual Incident Limits||Incident Limit||Lifetime Limit||Incident Limit||Lifetime Limit|
|Behavior Therapy||$150||Base Policy Limits apply||Not applicable|
|Alternative Therapy||$150||Base Policy Limits apply||Base Policy Limits apply|
|Wellness Care EndorsementReimbursements are up to the lower of the amount listed or charged||ROUTINE||ADVANCE|
|Heartworm Test or FELV Screen||$15||$15|
|Spay/Neuter and/ or Wellness Blood Screening||$80||$100|
|DOGS: Rabies Vaccine/ Titer or Lyme Vaccine/ Titer||$15||$15|
|CATS: Rabies Vaccine/ Titer or FIP Vaccine/ Titer||$15||$15|
|Canine DHLPP Vaccine/ Titer or Feline FVRCP Vaccine/ Titer||$15||$15|
|Microchip and/ or Urinalysis||$20||$20|
|Canine Bordetella Vaccine/ Titer or Feline FELV Vaccine/ Titer||$0||$15|
|Heartworm/ Flea Prevention||$0||$55|
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