What to do About Pre-Existing Conditions

Doug Kenney, DVM
Updated: June 17, 2011
Published: May 19, 2011
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A common reason that pet insurance claims are denied is because of a pre-existing condition. This is a problem or disease that your pet may have shown symptoms of or been diagnosed with before you purchased the policy, or that came to be during the waiting period before the policy became effective and coverage actually began.

However, each company’s definition of a pre-existing condition may vary, so it's important to read a sample policy or ask a company representative prior to purchasing an insurance policy.

For example, ruptured cruciate ligaments in a dog’s knee are considered by some companies to be a "bilateral condition" – a problem that occurs on one side of the body that is prone to also occur on the opposite side of the body. Therefore, if one side is affected prior to your purchasing a policy, issues with the opposite side will still be considered pre-existing, even if they occur after you purchase a policy.

Pre-existing cancer may also be an issue for you. For instance, if your pet develops cancer such as a mast cell tumor prior to your purchasing pet insurance. Some companies exclude coverage for any type of cancer, while other companies may exclude coverage for only mast cell tumor and cover all other forms of cancer.

And still other companies may cover a problem that occurred previously if it was "cured" and was not considered a chronic condition (no symptoms or treatment within the last 6 to 12 months).

So by purchasing a policy soon after getting a pet, preferably as a puppy or kitten, and before any known problems develop, you decrease the chances of having a claim denied because of a pre-existing condition. However, many pet owners interested in purchasing pet insurance have pets that have already been to the veterinarian several times with problems.

Recently, I corresponded with someone who was getting a new policy for his 10-year-old dog, who had been relatively healthy with the exception of a couple of problems. He went through the process I’m about to describe with satisfactory results.

During the application process, you will usually have to answer several questions about any previous problems your pet may have had. You should be completely honest when answering these questions. Knowingly misleading the insurance company about your pet's previous problems is considered fraud and the penalties range from the policy being canceled to possibly even being fined and/or imprisoned. Depending on your answers to these questions, the insurance company may issue a policy on your pet with no exclusions, or they may request further information from you and/or request your pet’s medical records for the past 12 to 24 months.

Even if you aren’t required to send in medical records during the application process, you will likely be required to send in medical records when you file the first claim. If you have forgotten to mention something during the application process, it may become evident when the company reviews the medical record and a condition could be considered pre-existing and excluded from coverage.

Therefore, during the application process, I recommend asking the insurance company if they will let you know in writing during the underwriting process if there are any conditions that will be excluded from coverage, and for how long because they are considered pre-existing. Most of the insurance companies will do this if you make this request, and it is worth asking about so that there aren’t any surprises down the road. The last thing you want to do is pay several months/years of premiums only to find out that a claim is denied because the insurance company considers a condition pre-existing before you bought the policy. They will usually require a copy of your pet’s medical record for review.

The goal is transparency on your part to reveal any known prior medical problems to the insurance company, and transparency from the insurance company to reveal (when the policy is initially written) if any pre-existing medical problems are excluded from coverage. If one or more conditions are excluded from coverage and you elect not to continue coverage, you can usually cancel the policy for a refund of premium as long as you haven’t filed a claim.

Another benefit of sending in your pet’s medical records during the application process is that when you do file your first claim, any questions about whether a condition is covered can be decided quickly and the reimbursement process will be expedited.

If your pet is older when you apply for a policy, the insurance company may request your pet’s medical records to review and even require a physical exam and/or lab testing to make sure your pet doesn’t have a chronic condition that would preclude coverage for illnesses.

Hopefully by following this process with your application, it will eliminate being frustrated with one of the more common complaints about pet insurance.

I would be interested to learn about any exclusions that were added to your pet’s policy during underwriting because of one or more pre-existing conditions. Also, have you had a claim denied because of a pre-existing condition?

Dr. Doug Kenney

Pic of the day: X-Ray of Jespah's knee after by jespahjoy

x-ray of dog knee, dog x-ray, cruciate ligament