Pet insurance claim accepted but limiting payout due to limitations that are not in T&C's

limefox

My cat went to the vet a week ago with a broken pelvis. 
The vet submitted a claim directly to the insurer and today I have had an email from the insurer saying they have part paid the claim and given a breakdown of what they haven't included for and referred me to the policy wording. 

When I took out the insurance i read thoroughly through the policy wording and t&c's and then I read through it again thoroughly when my cat went to the vet to be prepared for what costs might crop up. I was confident that other than the excess it would be covered. 

I have once again read through the specific parts of the policy wording that is referred to in the insurance payment remittance and still have no clue to any exclusions that they pet insurance are saying they have. 

This leaves me with a shortfall to pay the vet of approximately £300.

Am I missing something in the policy wording and do I just pay up or should I get the ombudsmen involved?

dunstonh

Am I missing something in the policy wording and do I just pay up or should I get the ombudsmen involved?

you cannot get the ombudsman involved at this point.  You have to go through the firms complaint process first.

 

Have you contacted them to ask them where in the policy documents does it say you were not covered ?   Be aware that some things need to be stated as being covered whilst some things need to be stated when excluded (typically, that means you are only covered for something if it is stated as being covered unless there is a stated exclusion in that area.  i..e you are covered for ABC unless its a result of XYZ)   You don't say what wasn't included in the breakdown. 

limefox

Thank you. The items they are limiting the payout for are as follows:

''*Please note we will pay up to £200 for consultation fees; inclusive of out of hours charges. Deductions have been made to

reflect charges which are considered higher than normal following guidance from our veterinary advisors. Please refer to the

Vet Fees section of your Policy wording.''

The vet fees section of the policy wording does not give any value or mention any limit for these charges as follows:

limefox

Ive noticed that there is another note within the policy wording that reads:

Specific Conditions
1.2.1 Level of vet fees allowed: We reserve the right to obtain a second opinion from our vet advisor where we consider:
 • Vet fees charged appear greater than conventional fees charged by an attending/referral practice; and/or
 • Treatment received may not have been required or may have been excessive when compared with treatment conventionally undertaken by an attending/referral practice.

Where there is a dispute we will pay only those vet fees deemed reasonable and essential by our vet advisor. We reserve the right to pay only up to a 100% mark-up on the manufacturer’s price for veterinary medicines, inclusive of any dispensing fee charged by your vet. 

So i assume they are not paying due to this clause.

The exact wording on the remittance for the 3 exclusions are as follows:

Hospital Admission Fee

*Please note, Admission fees are not covered under your policy terms and conditions. Please refer to the Vet Fees section of

your policy wording.

Out of hours fee

*Please note we will pay up to £200 for consultation fees; inclusive of out of hours charges. Deductions have been made to

reflect charges which are considered higher than normal following guidance from our veterinary advisors. Please refer to the

Vet Fees section of your Policy wording.

Hospitalisation

*Please note we will pay up to £100 per day/night for hospitalisation, which includes hospitalisation, examinations and

nursing care etc., as is conventional with other Vet Practices. Please refer to the Vet Fees of your Policy wording.

'

Sandtree

It would be easier to see the full policy doc, and the detail of the submitted invoice and their response... 

Certainly on the first point they are relying on 1.2.1 to say your vets charges are above what they consider reasonable and hence are settling that aspect at the rate their "advisor" has stated... I'd suggest the final point on hospitalisation is similar

limefox

Yes thats right. I dont think i can publish their full remitance or policy wording as there is a note in the t&c's that says I am not allowed to. 

Because it was emergency vet treatment it would be more expensive than standard vet treatment, but I am covered for emergencies. 

I dont know if I take it up with the vets practise to say they have overcharged, or complain to insurer and say they should pay out as its emergency rates for emergency vets. 

dunstonh

I dont know if I take it up with the vets practise to say they have overcharged, or complain to insurer and say they should pay out as its emergency rates for emergency vets.

Probably both.

Some vets have been known to have a different rate they bill for insured cases and those they bill for those that do not.   Hence why these clauses are in the insurance policy.

Equally, the insurer could be too reliant on pre-covid pricing.  Vets billing has gone up a lot over the last 18 months.

LippyDoodle

What company do you have the insurance with? 

limefox

LippyDoodle said:

What company do you have the insurance with? 

Its Animal Friends. Its their Prime policy. 

I am frustrated as I read through the policy wording thoroughly before I took it out, and again when I took the cat to the vet to know what would and wouldn't be covered. 

It seems highly unfair for there to be a clause that says if rates appear high they have the right to a second opinion (which they dont appear to have got as this hasnt been mentioned) and have now in their remittance given maximum amounts they pay out to for such items, which isnt listed anywhere in the policy wording 

Sandtree

limefox said:

Yes thats right. I dont think i can publish their full remitance or policy wording as there is a note in the t&c's that says I am not allowed to. 

Because it was emergency vet treatment it would be more expensive than standard vet treatment, but I am covered for emergencies. 

I dont know if I take it up with the vets practise to say they have overcharged, or complain to insurer and say they should pay out as its emergency rates for emergency vets. 

1.3.15 states emergency costs are only covered where deemed necessary, the wording you've posted isnt abundantly clear on their thinking... they say they'll pay £200 for the consultation inc out of hours... what was the total for this on the original invoice and how was this made up? 

Before going back to raise a complaint I'd want to know how they have come to their £200... is it a dispute on the hourly rate? The number of hours billed? The fact that out of hours was necessary?

I'd also speak to the vet given they are the ones that submitted the claim and find what their proposed course of action is. Dont have pets but have made PMI claims and in those the Dr's also deal directly with the insurer. I was initially concerned as the claims authorisation letter stated it'd cover 8 days as an in or day patent but the Dr was talking of a few weeks on a 7 days a week basis and then a few more scaling the number of days back. I spoke to the PMI provider who said they doubt that would fly but the Dr would be the one to submit the claims... never heard anything more about it and the total claim in the end was circa 37 days and paid without challenge.

limefox

The out of hours fee was £205

Its not an hourly rate, just a one off charge for out of hours. 

Then the additional items were consultation fee £62, admission fee £25.50, and then 1 night hospitalisation at £148, and 2nd night hospitalisation at £85.50

Saying that, the emergency vet should only have billed me for one night hospitalisation as the cat went in on the sunday night and then the monday was transferred over to the non emergency vets which has a totally different bill (not yet been claimed for)