Why would pet insurance deny a claim?
Most often, it's because the illness is deemed a preexisting condition, which few pet policies will cover. Challenging such denials can be frustrating, especially if your pet's medical needs are urgent.
In some instances, a claim being denied isn't because your insurance provider doesn't want to help. Instead, it can be due to a minor error such as incorrect patient information or data that was inputted incorrectly.
The claim has missing or incorrect information.
Whether by accident or intentionally, medical billing and coding errors are common reasons that claims are rejected or denied. Information may be incorrect, incomplete or missing.
If an insurance company denies a request or claim for medical treatment, insureds have the right to appeal to the company and also to then ask the Department of Insurance to review the denial. These actions often succeed in obtaining needed medical treatment, so a denial by an insurer is not the final word.
If your claim is denied by the pet insurance provider, and you disagree with the decision, you have the option to appeal. To do so, contact the insurer's customer care department. Before you do so, though, consult the coverage provisions of your policy, where you might find an explanation for the company's decision.
Some of the most common things pet insurance does not cover are: Pre-existing illness or injury - In general, insurers will not cover illness or injury that your pet had or showed signs of having before the policy started.
Most insurance companies will allow you to appeal a denied claim. However, the likelihood of a reversed decision is slim. If you haven't already consulted a lawyer about your claim, you may want to do so quickly after your claim is denied.
- Timely filing. Each payer defines its own time frame during which a claim must be submitted to be considered for payment. ...
- Invalid subscriber identification. ...
- Noncovered services. ...
- Bundled services. ...
- Incorrect use of modifiers. ...
- Data discrepancies.
- Claim is not specific enough. ...
- Claim is missing information. ...
- Claim not filed on time (aka: Timely Filing)
Most common rejections
Duplicate claim. Eligibility. Payer ID missing or invalid.
What is the difference between insurance claim rejection and denial?
A claim rejection occurs before the claim is processed and most often results from incorrect data. Conversely, a claim denial applies to a claim that has been processed and found to be unpayable. This may be due to terms of the patient-payer contract or for other reasons that emerge during processing.
Bad faith insurance refers to the tactics insurance companies employ to avoid their contractual obligations to their policyholders. Examples of insurers acting in bad faith include misrepresentation of contract terms and language and nondisclosure of policy provisions, exclusions, and terms to avoid paying claims.
- Review the policy. Understand what is covered.
- Review the denial letter. ...
- Keep records. ...
- Follow your insurance company's internal appeals process. ...
- Provide additional information. ...
- Consider an external review. ...
- Speak to an attorney.
Processing a pet insurance claim is usually straightforward and your payout should take between seven and 10 working days. If you'd like an estimated date for the payout, call your insurance provider. Depending on who you're with, you may be able to track your claim's progress online.
If you are waiting for a claim to be assessed and paid updates will be provided in My account. For any other refunds, this can take between 5 and 10 working days to reach your bank account.
Accidental damage insurance that might include cover for pet damage doesn't usually come as standard with your home insurance, but you can add it to your buildings and contents insurance policies for an extra fee. It typically covers repairs or replacement if an item is broken or damaged by accident.
It's usually not too difficult to know when you should claim, and you can always check your policy documents or speak to your insurance provider if you're not sure. The only time it might not be worth claiming is if your policy excess – that's the amount you pay to make a claim – is more than the cost of the treatment.
Usually not covered: Preventive care
A standard pet insurance policy won't cover many common vet expenses a new pet parent faces, such as spay or neuter surgery, vaccinations and annual checkups. Insurers consider these services to be routine care and won't pay for them under an accident and illness plan.
How do pet insurers know about pre-existing conditions? Depending on your insurer, when you submit a pet insurance claim, they will typically request your pet's medical records to evaluate the claim and determine if the issue predates your waiting period.
In 2021, insurance companies denied on average 17% of in-network claims filed. Claim denials leave people, who pay insurance companies thousands of dollars in premiums to cover their health care costs, with hefty medical bills and medical debt. Yet, almost no patients challenge these denials. But they should.
When a claim gets denied?
If the insurer denies the claim, the patient is responsible for the claim amount. In both scenarios, the insurer can either approve or deny the claim. If they approve the claim, the bill is paid. If not, the consumer can appeal the denial.
Ask the insurer to explain the reason for the denial in writing. Review your policy to see if you should be covered. Ask the medical provider to help you get answers from the insurer. Take notes about all discussions with the insurer and the health care provider (include dates, names and what was said).
Dirty Claim: The term dirty claim refers to the “claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment”.
By addressing issues such as inaccurate documentation, coding errors, lack of medical necessity, timely filing limits and insurance coverage problems, providers can significantly reduce claim denials and improve overall financial performance.
A provider can resubmit a rejected claim once the errors are corrected because the data never entered the insurance carrier's system (not processed). Some providers and facilities have electronic medical record systems that catch these errors before submission to the insurance carrier.
