molly's mom, your warning is very important, you bring attention to the art or skill of using insurance, which i learned from experience as well. The key thing to making it work on your behalf is the wording of claims and medical records.
You have a good chance to succeed on an appeal if you want to go to the trouble. At this point, it depends on what vets are willing to write. If the neurologist or another vet is willing to write a clarification making clear that the owner did not report any symptoms that a reasonable person would think were SM until just before bringing the dog for evaluation, you can begin to have the exclusion removed. It would be likely that Petcare would want further clarification from the vet, another letter, a phone interview, which the vet might initiate.
In my case, a vet wrote down that zack had an enlarged heart based on looking at an abdominal xray. He wrote it down in big letter in the chart. (this was at the ER). the vet was wrong and the following day he talked to the radiologist who said the heart was likely normal, he wrote that down in the chart on another page, in small writing. He did not write "What i wrote yesterday was wrong, Zack does not have an enlarged heart," although he said that to me on the phone, not that he had been wrong explicitly but that there was nothing to worry about the heart, "his heart is fine."
when i got the policy from petcare wiht the exclusion, permanent, for anything related to the heart, i called them and said this is a mistake, and told them that the vet had made a mistake when he wrote enlarged heart and tht on the next day he told me the heart was fine, based on the radiology consult. the petcare rep said ok, fine, just have the vet document that.
Easier said than done. Neither he nor the radiologist would explicitly say that the diagnosis had been wrong, allthought both said to me that his heart was fine. the radiologist was militantly anti-insurance and wanted to do anything she could to help i asked her and and faxed me a copy. I was disappointed to see how ambiguous it was. After they got her letter, they said it hadn't been made clear that the heart was fine. Well, vets can't really say his heart is fine, without an echocardiogram, they can only say all his heart signs were normal, but this was too ambiguous to cancle "Enlgarged heart" in big writing on his chart. Unless someone would say "the other vet made a mistake," which wasn't something they apparently wanted to say on record. The radiologist then called Petcare to ask what they wanted her to write in order to get the exclusion removed. They told her what to write and said it would be removed. She wrote it and sent me a copy, just a day or two after her first letter. she was also in close touch with me, calling me, et, she really wanted to help, she felt bad about the mistake and did not like insurance companies either. Again, the letter was ambiguous, it said all of zack's heart signs were normal, that heart disease was a very rare cause of vomiting in a dog that age and that abdominal xrays could not tell anything about heart shape or size.
So, petcare sent me a new policy and they changed the permanent exclusion on the heart to a temporary exclusion. Progress, but that wasn't good enough. they onlyl want to get the temporarly exclusion removed apparently would be an my expense to have an echo gram for $500, after a year. A normal echogram. If it wasn't normal and they excluded the heart, that wouldn't be fair since there was no valid reason to exclude the heart in the first place, the vet had made a mistake, what he noted in the chart was wrong so it shojld not be seen as a pre-existing condition but as a vet mistake.
At that point, i looked into filing a complaint with the insurance commission. That is a definite real and important option. I can see that Petcare was not being unreasonable in the actions they too. The doctor was not clearly saying that the notation of enlarged heart should be ignored, explicitly, you had to do a lot of reading between the lines to get that. But it was there, if you read between the lines. Petcare claim adjusters are just don't look at claims tht quickly. They look for clear eay to see writing that is siimple and to the point.
If your claims are clear and to the point, they won't probe around and try not to pay. If a vet signs it and it's a clear notation of a condition or diagnosis, they just will pay. 'Enlarged heart' was very clear. The modifications of that were definitely not.
So, the insurance commisssion website has an online form to fill out to make a complain. They say before you make a complaint, to attempt to resolve it with the insurance company. So, i called PetCare and asked to speak to their complaints department. I was put in touch wiht a certain person. I wrote her a long letter spelling out all the things the vet left to implication and said that a reasonable person would look at this and see that there was no evidence that Zack had an enlarged heart and no grounds for an exclusion. i sent it by email. She emailed right back and said she was having someone contact the radiologist to clarfiy things. She then quickly wrote back and said the exclusion was removed and she would send me a new policy.
If you PM me, i'll give you more details., contact info etc.
At this point it's all about what a vet will write to them.
If i was in your position, i would call petcare and say "a mistake has been made. My dog developed symptoms that concerned me long after the 30 day waiting periond. Then i took her for an evaluation to see if it was something neurological because i had read about something that i thought it might be. The neurologist i went to asked me how long the dog had been scratching and i gave a rough estimate offf the top of my head, but i wasn't sure, i wasn't thinking about being precise. He wrote it down adn the date was before the end of the waiting period. But in fact, the symptom was just scratching. It wasn't a scratching i was concerned about at the time, and i still do'nt konw if it was related to the condition, there was no reason at the time to think it was. Puppies often scratch, it was normal scratching, it was not over a lot, but being a new mom, i took note of every move the dog made, of courses. But there has been a misunderstanding, i never had any concern about this disease until months later, there would have been no reaason to, and i did get concerned about some different symptoms that came long later, and immediately took her in. So i need to get this clarfiied. Please tell me what Petcare needs for my vet to say, in order to clear up that this condition or symptoms of it, were not noted until (whatever date you said, Decmember?). Ask her what they would need for the vet to say. They are very nice and present themselves as supportive (i talked to lots of them during my ordeal and they did try to help me to konw what i needed to do, and my vets didnt' do it, but eventually it got straightened out, it was a hassle but i felt i had to go through it, it was too important to have the heart covered). It's all about playing by the rules with them. They will tell you the rules they go by, to help you know how to get what you need.
After you make your case, wiht your vet documentation (and it might require more than one vet letter and documented phone call, and you might print up stuff from the web about SM showing that your puppy had nothing special goihng on durign the waiting period that would lead to a concern asbout SM, and scratching is nonspecific, and only a minority of SM dogs have it, and it's usually a special kind of scratching--the point of making a case, a REASONABLE case that you had no reason to be concerned about SM at that early point and the vet's notation was based on a misunderstanding or miscommunication which can be easily cleared up, the point of this is, if you make a complaint to the insurance commission you want to show petcare that a reasonable person will see things your way, and tell them that you really want to work it out with them but are frustrated and have looked into making a complaint because your request is not unreasonable, but the the complaint process requires first tryig to work it out with the insurance company so that's why you are writing to her (their claims manager administrator, or whatever her title is).
At this present stage, it's about talking to your neurologist, saying "Here is the misunderstanding. I need to clear it up. Here's what petcare said they need to have documented, i need a letter to them from you, and here is their phone number if you want to call them. Please fax me a copy of anything you send them and call me and let me know what they say if you talk to them on the phone. I'm appealing the exclusion because i had no worry about SM during the waiting period and no vet had any worry about SM during the waiting period, and there is a misunderstanding.
before talking to the vet, ask petcare what they need for the vet to say, more or less, or specifically if possible. you can be completely honest, it's a misunderstanding, it could happen to anyone in that position, and now it needs to be cleared up, it's nobody's fault, they are your team , to help your animal get the care it's entitled to, and you need their help in clearing the misunderstanding. They talk to customers all the time about these things and they will tell you.
it's a hassle and i'm really sorry you have to go through any of it. Again, your warning to people here is important, i've had to learn by trial and error, if knew then what i know now, i could've gotten my problelm cleared up faster. My progress was to some extent slowed down by my own assumptions that petcare was trying to avoid covering zack's heart for any reason beyond needing a certain wording from a vet. That became somewhat of a self fulfilling prophecy. If i'd seen them more optimistically i could've gotten it taken care of faster. It was all about communication.
you can work with vets, being conscious of this. All the vets i've worked wiht have been very eager to help get the insurance to cover whatever it was.
I totally agree that you should appeal the exclusion and think you have a very good chance, based on what i learned from dealing with them with an exclusion (of everything to do with the heart! :yikes). My impression when all was said and done was that they did not have an agenda to exclude the condition because it might be expensive for them, but rather that they were just playing by the rules, and the wording was such that they would certainly exclude it, after dealing with having them remove this exclusion and making a couple of claims, i think they are pretty mindless in evaluating claims--if it's worded right, i think they will simply pay without hesitation.
A dog who has SM can be scratching for some other reason,SM dogs can get allergies too, or dry skin. Your vet or neurologist should be able to clear this up. A history of scratching reported in retrospect isn't enough to exclude SM, unless it's worded in a way (which it was) to make it sound like it was linked to SM. At this point, the vet may be able to clear up that the condition was only suspected shortly before the presentation for evaluation and diagnosis. Do you have the medical records showing what was written? I think it's really on your vet now, and one letter from the vet may not be enough, but it should be worth fighting for. The exclusion is wrong, there's no need to get moralistic about it with PetCare, it's about the wording, they play by the rules.
it's really unfortunate that you have to go through this, and others can definitely learn from your story.
In my case, an ER vet had illegitimately interpreted an abdominal xray as showing an enlarged heart, he wrote it in the chart in big letters, 'enlarged heart.' The next day he consulted with the radiologist who said the heart looked normal and the ER vet wrote in the chart that she said 'heart appears WNL' (within normal limits)....in SMALL letters.
When petcare got those records, they saw 'enlarged heart,' and proceeded to give a permanent exclusion for anything to do with zack's heart, he was just 4 months old and his heart was fine.
Try to get a vet to come out and say "I made a mistake when i wrote that down."
PetCare asked me to get a letter from the doctor, saying that the notation of enlarged heart was incorrect. I found out that was not going to happen. However, the radiologist really wanted to help, she was militant hostile toward insurance companies, and she immediately wrote a letter saying the heart signs were normal. She said that abdominal xrays did not provide information that would allow any conclusions about heart size or shape. But this letter was ambiguous, it didn't say zack DIDN'T have an enlarged heart. So petcare didn't remove the exclusion. Then the radiologist called them and spoke to someone who said Petcare just needed a letter saying the examination showed normal pulse, heart rate, etc, on auscultation, so the radiologist wrote that up and said that i "would like enlarged heart removed from Zack's records." To me, this was a lot of beating around the bush when the bottom line was, the other vet made a mistake, there is no basis for saying the heart was enlarged, it was a mistake.
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