ComplaintsforPTZ Insurance Agency, Ltd.

Pet Insurance

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Initial Complaint
04/17/2024
Complaint Type:
Customer Service Issues
Status:
Answered
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
RUN FOREST!! RUN!!! I signed up for ASPCA pet insurance 4 moths ago and my dog quit eating and also vomited. I filed about 800 dollars in claims and they paid ZERO to me. . They denied paying because they said he may not be eating because of his teeth and thats pre-exsisting gum disease even though the vet told me he doubted that was the reason he wasnt eating! In fact a vet ran a urine test that came back later and found out the dog had a UTI! When the uti cleared up the dog started eating again!!! HOWEVER ASPCA REFUSES TO PAY because the vet mentioned he had ******(gum disease) and needed a teeth cleaning when he got over his sickness which was NOT related to the teeth!! They have a confirmed UTI in the medical records!Also the ASPCA pet insurance rep that responses here to people always says "You can file an appeal" BUT they dont tell you THE APPEAL IS DECIDED BY THEM!..LOL. Not a independent review team like other pet insurance companies! Imagine going to court for speeding and instead of a judge you get another police officer deciding whether to decide for you or the police officer!!!..lol They need a independent appeal review!I wish they would either pay the claims or just refund my premiums. It cost my almost 400 dollars the last 4 moths months!!! Then they also keep saying they need records, i call and email them the records then they say they got everything. Then i wait and nothing happens and they say they need medical records. I send them again they say they got them and then the computer shows they are waiting on medical records.BEWARE! They wanted FIVE years of medical records from every vet, dont believe them when they tell you they want a year or two. They will keep going back and back and the contract you sign says they can ask for every visit from the time they are a puppy!!!! EVERY RECORD!!!! Im not kidding!!! and if your dog sneezes when he was a puppy they can say 10 years later he had signs of allergies and not pay a allergy claim 10 years later as an example because allergies are considered non curable and a sneeze can be a symptom of an allergy!...lolAlso if my dog develops heart problems or other problems will you blame it on the teeth and not pay anything either????BEWARE!! This company gives you a false since of security!!! Please either refund my premiums or pay the claims!!! If you cant pay for the sick claims because of the teeth then please refund my money! Done let me be OUT both the premiums and the pet visits! Thats cruel! I would have never guessed you would have blamed the teeth for the dog being sick for excuse not to pay!Other pet insurance companies will tell you up front what will and wont be covered. This company doesn't, you pay the premiums and get blind sided then you are out the premiums and the cost of care!!
Business response
04/23/2024
Dear Customer Relations,

We are in receipt of your April 17, 2024,inquiry relative to the above-mentioned policy holder regarding his Accident and Illness Policy (PET-P-20000-0723) for his dog. Per the Better Business Bureau direction, we have removed any reference that will personally identify our customer. The pet ********************** policy is a personal lines property and casualty product filed under inland marine.

The customer is disputing multiple medical record requests as well as a claim denial.

There are 6 vets associated with the account. We requested medical records from January 1,2019 to present due to the age of the pet (12 years) and multiple possibly chronic conditions present.

The customer is also disputing the denial of a claim wherein submitted veterinary expenses were excluded from coverage as treatment of a pre-existing condition (periodontal disease), which occurred prior to the December 16, 2023 effective date of the policy. This determination was based on the available medical records at the time of the claim review.

Lastly, the customers complaint indicates a possible resolution of refunding their premiums back to inception. We are attempting to reach the customer directly to resolve the matter. Per the customers request, our **************** Representative will follow up on Wednesday,April 24, 2024.

Thank you for the opportunity to respond.
Initial Complaint
03/05/2024
Complaint Type:
Product Issues
Status:
Resolved
The complainant verified the issue was resolved to their satisfaction.
Hello, I got pet insurance for 2 of my dogs through ASPCA back in July/2023. I filed my first claim for one of my dogs who got sick September 18 2023.I had no response from the company for months. They came back months later and told me the claim will not be reimbursed, violating the terms of our contract. I contacted them again and had my vet send them the invoice, and I personally submitted the invoice as well. I did not receive a response from them again, even after sending them multiple emails. I had my bank dispute the charges for the payments i've been making every month and they canceled my insurance and did not reimburse me for my payments. The last email I sent I told them if they do not reimburse me for all the payments I made I will be filing a complaint and they finally answered after that. They did not take me seriously until I threatened to report them. I gave them a call back and was told a supervisor will contact me this past Friday and no one called. I would like a full refund for all the payments I have made to this company since they not only violated our contract but also failed time and time again to respond to me or update me on the matter. Thank you.
Business response
03/15/2024
We are in receipt of your March 5, 2024,inquiry relative to the above-mentioned policy holder regarding her Accident and Illness Policy (PET-P-20000-0920) for her dog. Per the Better Business Bureau direction, we have removed any reference that will personally identify our customer. The pet ********************** policy is a personal lines property and casualty product filed under inland marine.

The customer expressed concern as it relates to customer service and coverage of a submitted claim. Please refer to the following timeline as it relates to this matter.

9/18/2023            Claim was received.
10/17/23              Record request was sent to the treating clinic for dogs medical records.
10/18/23               Partial records were uploaded via the online member center (only the discharge instructions, not full records).
10/18/23               We received a response from the clinic stating they had not seen the patient since 2020. Based on the clinics response, the claim was denied as needing records.
10/19/23               Customer sent an email requesting to cancel their insurance and provide a full refund. **************** responded via email advising why claim was denied, what was needed, and advised how to cancel. Customer emailed again and confirmed request to cancel.
10/20/23               The policy was canceled effective 10/19/23.
10/23/23               Both pets last coverage dates were changed to 7/19/23 due to chargebacks.
10/26/23               The last coverage dates were changed back to 10/19/23 due to chargeback reversals. Email sent to customer explaining prorated refund. The customer responded the same day with medical records via email.
11/4/23                 Customer email is documented in our system stating records were sent.
11/6/23                 We replied to the customer email advising that we did not receive the requested medical records.
1/23/24                 Received customer email regarding full refund for both dogs and notification of BBB complaint.
1/29/24                 Voicemail was left for the customer regarding necessary records required to reopen the claim.
2/27/24                 The customer called and requested full refund for insurance.
3/6/24                  Last coverage date was adjusted to 7/19/23 per the customers request.
3/7/24                  Additional refund issued from the adjustment of the last date of coverage.

At this time, we consider the matter to be resolved. Thank you for the opportunity to respond.
Customer response
03/18/2024
Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
Initial Complaint
02/20/2024
Complaint Type:
Service or Repair Issues
Status:
Answered
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
I signed up with this company through ASPCA thinking that it was a reputable company. My dog developed a new condition as we moved to a new city. The new vet couldn't determine the issue but the insurance decided that it was a previously existing condition and refused to cover the vet visit fees.
Business response
02/13/2024
Dear Customer Relations:
We are in receipt of your January 31, 2024, inquiry relative to the above-mentioned policy holder regarding his Accident and Illness Policy (*******************) for his dog. Per the Better Business Bureau direction, we have removed any reference that will personally identify our customer. The pet insurance policy is a personal lines property and casualty product filed under inland marine.
The customer is disputing the denial of his claim due to a pre-existing condition, which occurred prior to the July 19, 2023, effective date of the policy. We based our decision to exclude coverage on a review of medical records, which document the dog’s symptoms (seasonal allergies) consistent with conjunctivitis were first noticed July 3, 2023, placing the onset of symptoms prior to inception. Coverage is determined based on the occurrence of symptoms recorded in the records, not on the date of exam or final diagnosis.

Please see below for applicable excerpts from the Accident and Illness Policy as it relates to pre-existing conditions.

DEFINITIONS
Occur or Occurrence – When signs or symptoms related to a condition first were observed by any individual, recorded in your pet's medical record, or would have been detectable by a routine physical veterinary exam.
Pre-Existing Condition – Illness, disease, injury, or change to your pet's health that first occurs or shows symptoms before coverage is effective or during a waiting period. This includes conditions that are related to, secondary, or resultant from a pre-existing condition.
CURED CONDITION ELIGIBILITY
If your pet's pre-existing condition is curable and has been cured and free from treatment and symptoms for a period of 180 days it is a new occurrence. This does not apply to ligament and knee conditions.
WHAT IS NOT COVERED
Exclusions
We will not pay for costs associated with or resulting from the following:
r. Pre-existing conditions that occurred on or before the first effective date of the applicable coverage or during a waiting period.
Upon further review of the veterinary records, the company determined there is question of fact that the conjunctivitis is directly linked to the seasonal allergies documented on July 3, 2023. As such, we have submitted the related veterinary expenses to be reprocessed in accordance with the terms and conditions of the Accident and Illness policy. After satisfying the annual deductible, reimbursement was issued to the ACH account on file.

Lastly, per the customer’s request, coverage was cancelled effective January 30, 2024, and a pro-rated refund has been issued. At this time, we consider this matter to be concluded.

We hope that the information provided in response to your inquiry is satisfactory. Thank you for the opportunity to respond to this matter. If you have any questions or need additional information, please contact me at ************.

Sincerely,

****** ********
Compliance Specialist
ASPCA Pet Health Insurance
PTZ Insurance Agency, Ltd. (NPN #*******)
***************************
Customer response
02/13/2024

Complaint: ********

I am rejecting this response because: as stated in the vet’s statement, she was unable to determine the cause of the symptom. The insurance provider is acting as a medical professional in assigning a cause to my dog, which as indicated in BondVet’s record that the vet was NOT able to provide a conclusive diagnosis.

Sincerely,

******* ***
Business response
02/27/2024
Dear Customer Relations:
We are in receipt of your February 21, 2024, follow-up inquiry relative to the above-mentioned policy holder regarding his Accident and Illness Policy (*******************) for his dog. Per the Better Business Bureau direction, we have removed any reference that will personally identify our customer. The pet insurance policy is a personal lines property and casualty product filed under inland marine.
The customer expressed continued concern regarding the initial denial of his claim due to a pre-existing condition, which occurred prior to the July 19, 2023, effective date of the policy.

As indicated in our February 13, 2024, response, upon further review of the veterinary records, the company agrees there is question of fact that the conjunctivitis is directly linked to the seasonal allergies documented on July 3, 2023. The initially denied veterinary expenses were reprocessed in accordance with the terms and conditions of the Accident and Illness policy. After satisfying the annual deductible, reimbursement was issued to the ACH account on file. As such, we consider this matter to be concluded.

Thank you for the opportunity to respond to this matter. If you have any questions or need additional information, please contact me at ************.

Sincerely,

****** ********
Compliance Specialist
ASPCA Pet Health Insurance
PTZ Insurance Agency, Ltd. (NPN #*******)
***************************
Initial Complaint
01/31/2024
Complaint Type:
Customer Service Issues
Status:
Answered
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
I called in to ASPCA Pet Insurance on January 30, **** and spoke with ***. I was not pleased with the lack of knowledge she had with my pet's status of claim. *** told me that no medical records were received from the Vet and I told her according to the ASPCA's app it shows it was received, so at that point I was irritated but I was calling about ASPCA asking for medical records from 7 years ago that my pet did not have. She offered no help at all, so I asked her could I speak with a manager and she put me on hold for seconds and came back to tell me no manager is available. I was already irritated with her so that escalated my irritation so I told her to cancel the insurance because she did not offer any help and she knew nothing. I paid 2 months of insurance to protect my pet and all ASPCA did was collect my money without doing anyting. I was all my money back from day 1 and that should be a total of $88.28.
Business response
02/09/2024
Dear ****************:

We are in receipt of your January 31, ****,inquiry relative to the above-mentioned policy holder regarding her Accident and Illness Policy (PET-P-20000-OH-0723) for her cat. Per the Better Business Bureau direction, we have removed any reference that will personally identify our customer. The pet ********************** policy is a personal lines property and casualty product filed under inland marine.
The customer expressed concern as it relates to coverage of her submitted claim.
The customer enrolled her cat on the Accident and Illness Policy (PET-P-20000-OH-0723)with an effective date of December 30,2023. The policy subsequently renews on an annual basis.
On January 16, ****, we received a claim submission. To properly process the claim, we required medical records. Upon identifying the veterinary facility the pet had been to, we sent multiple requests for the required information per the customers signed authorization on the submitted claim form. Please also refer to the following excerpt from the customers insurance policy regarding claim submission as well as authorization to request medical records:
CLAIMS

Submit a Claim

So we can process your claim as quickly as possible, submit your claim electronically and include the following information with your claim:

Your name, address, contact information, and signature on the claim form.
A description of the condition and treatment you are claiming.
All applicable receipts including an itemized breakdown of the fees incurred for actual costs after any discounts or credits.

Failure to provide complete information may result in:

Denial of your claim.
You submitting a new claim with all required details.

Other Claim Procedures
When you submit a claim, you authorize us and our administrator to access all medical information and records that we need to assess your pets health and you agree to provide us with any missing medical information and records. For example, we may ask you for the name and contact information of any veterinarian that has ever seen or treated your pet. You must also provide proof of identity for your pet when we request.

If you choose, your veterinarian can submit a claim on your behalf.If you so indicate on your claim form, we can pay the veterinarian directly.

Payment of one claim does not guarantee that we will pay additional claims.

On January 30, ****, the customer reached out to our *************************** inquiring about the status of her claim. Our representative confirmed records were received, attached and under review. The customer requested to speak with someone in our ***************** to determine if what we received was sufficient. Our agent advised Claims representatives are unavailable to speak with. The customer asked for a supervisor and a follow-up return call was scheduled. Our ******** Service Supervisor reached out to the customer the same day and per the customers request the plan was cancelled back to inception, as a one-time courtesy. A full refund has since been processed and the submitted claim was cancelled due to no coverage in force. Accordingly, we consider this matter concluded.
We hope that the information provided in response to your inquiry is satisfactory. Thank you for the opportunity to respond to this matter.
Sincerely,
*****************************
Compliance Specialist
ASPCA Pet Health Insurance
PTZ Insurance Agency, Ltd. (NPN #*******)
*************************************************************
Initial Complaint
12/28/2023
Complaint Type:
Sales and Advertising Issues
Status:
Answered
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
On 11/18/2023 my dog had to go to the vet for IVDD and ended up needing extensive medical care and spinal surgery. I previously had signed up for ASPCA Pet Insurance (managed by PTZ insurance agency) because they claimed in their advertisements that pre-existing conditions would be covered as long as there have been no symptoms for more than 180 days. My dog had previously experienced IVDD back in January of 2022 which resulted in a surgery that we told the insurance about. They even have a section of their site that goes over how they cover IVDD. When I submitted my claims (two separate claims for two separate vet offices) in the amount of $10,034.26 and $1,138.90 a few days later on 11/21/2023, I gave the company my dogs medical records dating back to January of 2022. I had confidence that my claim would be completed in the 10 days that they had initially told me it would. A few days later they changed it to 2-4 weeks since they required additional documentation which I immediately supplied to them. They did not touch the claim after uploading these documents for a week. By the time they finally denied my claim the whole process took over a month. I believe that their advertising is incredibly misleading because if they claim to cover pre existing conditions that have not had symptoms for more than 180 days (other than ligament and knee conditions) then why was my claim not covered. They should also be more clear about in what instances they cover IVDD more specifically on their website and in their advertising. I wholeheartedly do not recommend getting this insurance for your pets. They will just take double the amount of time they initially say only to deny your claim and they have dishonest and misleading information and advertising.
Business response
01/08/2024
Dear Ms. ******:

We are in receipt of your December 29, 2023, inquiry relative to the customer’s Accident and Illness Policy (****************) for her dog. Per the Better Business Bureau direction, we have removed any reference that will personally identify our customer.

The customer expressed concern for coverage of pre-existing conditions.

First, to properly assess the customer’s submitted claims, we required additional medical records. Upon identifying the veterinary facility the pet had been to, we sent the necessary requests for the required information per the customer’s signed authorization on the submitted claim forms. Please also refer to the following excerpt from the customer’s insurance policy regarding authorization to request medical records:
CLAIMS

Other Claim Procedures

When you submit a claim, you authorize us and our administrator to access all medical information and records that we need to assess your pet’s health and you agree to provide us with any missing medical information and records. For example, we may ask you for the name and contact information of any veterinarian that has ever seen or treated your pet. You must also provide proof of identity for your pet when we request.

The customer is disputing the denial of her dog’s Intervertebral Disc Disease (IVDD) as a pre-existing condition, which occurred prior to the August 19, 2023 effective date of the policy. We based our decision to exclude coverage on a review of medical records, which document the dog’s IVDD initially occurred January 2022. This is reiterated in the BBB Complaint. IVDD is a chronic degenerative illness affecting the spinal column and is considered to be an incurable condition. Based on this information, the submitted veterinary expenses were correctly excluded from coverage since coverage is determined based on the occurrence of symptoms recorded in the records, not on the date of exam or final diagnosis.

Please see below for applicable excerpts from the Accident and Illness Policy as it relates to pre-existing conditions.

DEFINITIONS
Occur or Occurrence – When signs or symptoms related to a condition first were observed by any individual, recorded in your pet's medical record, or would have been detectable by a routine physical veterinary exam.
Pre-Existing Condition – Illness, disease, injury, or change to your pet's health that first occurs or shows symptoms before coverage is effective or during a waiting period. This includes conditions that are related to, secondary, or resultant from a pre-existing condition.
CURED CONDITION ELIGIBILITY
If your pet's pre-existing condition is curable and has been cured and free from treatment and symptoms for a period of 180 days it is a new occurrence. This does not apply to ligament and knee conditions. WHAT IS NOT COVERED
Exclusions
We will not pay for costs associated with or resulting from the following:
r. Pre-existing conditions that occurred on or before the first effective date of the applicable coverage or during a waiting period.
Lastly, please note, The customer is made aware of the terms and conditions, including but not limited to the pre-existing exclusion, waiting periods, limits, co-insurance, and deductibles prior to enrolling a pet. Also, sample plans are available for review.   If a consumer enrolls and is later dissatisfied with coverage as they are reviewing their policy documents at home, they can cancel within the first 30 days and receive a full refund. Further, if a customer knows their pet(s) will be receiving specific treatment, they can submit an estimate to us prior to having the treatment done and receive an estimate of reimbursable benefits.

We hope that the information provided in response to your inquiry is satisfactory. Thank you for the opportunity to respond to this matter. If you have any questions or need additional information, please contact me at ************.

Sincerely,

****** ********
Compliance Analyst
ASPCA Pet Health Insurance
PTZ Insurance Agency, Ltd. (NPN #*******)
Initial Complaint
11/29/2023
Complaint Type:
Billing Issues
Status:
Resolved
The complainant verified the issue was resolved to their satisfaction.
I have a puppy for which I had purchased insurance. The insurance turned out to be a scam. I absolutely was not going to renew the insurance, so let it slide when November, 2023 approached. I have received a bill from a credit card company I use and see that a charge for another year of the insurance was put on the card. I DID NOT AUTHORIZE THIS CHARGE!!! I have called them and they are refusing to credit my card with the amount of $373.68, which is the amount they now owe me. This will also involve interest charges from the bank that holds my credit card. I am filing a complaint with your company against this pet insurance company and demanding that they credit my card with the above amount as well as any bank charges accrued. This pet insurance company also tells me they sent an email which I did not see. If it was spam, it goes to spam, and I delete immediately. I do not read spam. Thank you for helping in this matter.
Customer response
11/29/2023
I am not able to send attachments due to lack of knowledge concerning the computer. I was charged $373.68, a charge that was put on a MasterCard without my knowledge nor consent. I do not have a copy of that at this time. I am requesting that this company be notified of their responsibility to take that charge off my credit card, plus any interest charges put on by the bank this card uses. I am not going to be paying anything for which the insurance company had no authorization to bill my credit card. I am requesting your help in getting this matter resolved.

***********************
Business response
12/11/2023
We are in receipt of your November 30,2023, inquiry relative to the above-mentioned policy holder regarding the Accident and Illness Policy (PET-P-20000-**-0920) for her dog. Per the Better Business Bureau direction, we have removed any reference that will personally identify our customer. The pet ********************** policy is a personal lines property and casualty product filed under inland marine.

The customer expressed concern as it relates to the automatic renewal of her dog insurance policy.

The customer enrolled her dog on the Accident and Illness Policy (PET-P-20000-**-0920) with an effective date of August 12, 2022. The policy subsequently renews on an annual basis. The customer was contacted on November *******, with an automated phone call reminding her of the upcoming automatic renewal. The customer called us to cancel on November 27, 2023, and requested a full refund. The customer was given a full refund.
At this time, we consider this matter to be resolved.

We hope that the information provided in response to your inquiry is satisfactory. Thank you for the opportunity to respond.
Customer response
12/12/2023
Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
Initial Complaint
10/24/2023
Complaint Type:
Service or Repair Issues
Status:
Resolved
The complainant verified the issue was resolved to their satisfaction.
This is a pet insurance company that we paid for pet insurance. We needed to use it for our dog **** and they have yet to mail our reimbursement after paying the vet. It is extremely hard to communicate with them and all we get is the run around. The vet service was performed in September and our claim was complete in early October. We were told it was mailed on the 6 th of October and to this date ( the 24) it still has not arrived.
Customer response
10/27/2023
Hi, this company finally responded stating they mailed our reimbursement on 10-9 and if we haven’t received it please contact them to verify our address and or have a new check mailed. I responded by telling them they have the correct address and go ahead and send a new check. I honestly do not believe they sent a check so I will be forwarding the requested info to you. There’s no way a check from Ohio to Tennessee should take 3 weeks to arrive. Respectfully **** *********
Customer response
10/27/2023
I sent the requested info via email because they would not load up here. ******* *********
Business response
11/08/2023
Dear Ms. ******:
We are in receipt of your October 30, 2023, inquiry relative to the above-mentioned policy holder regarding the Accident and Illness Policy (****************) for his dog. Per the Better Business Bureau direction, we have removed any reference that will personally identify our customer. The pet insurance policy is a personal lines property and casualty product filed under inland marine.
The customer enrolled his dog on the Accident and Illness Policy (****************) with an effective date of May 27, 2022. The policy subsequently renews on an annual basis.
In his inquiry, the customer expresses concern regarding claim reimbursement.
We received a claim on September 7, 2023. Upon receipt of the required information to properly adjudicate the claim, the eligible reimbursement was issued via check and mailed to the customer’s address on file on October 6, 2023.
Upon receipt of the BBB complaint, we reviewed the customer’s account including all interactions and confirmed that the communications regarding the claim in question were acknowledged and responded to.
The customer spoke with one of our agents on October 25, 2023 (day after BBB complaint filed) indicating the reimbursement check was not received. In an attempt to resolve the matter, the reimbursement check was reissued and mailed to the same address on file.
We hope that the information provided in response to your inquiry is satisfactory. Thank you for the opportunity to respond to this matter. If you have any questions or need additional information, please contact me at ************.
Sincerely,
****** ********
Compliance Analyst
ASPCA Pet Health Insurance
PTZ Insurance Agency, Ltd. (NPN #*******)
***************************
Customer response
11/08/2023
Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
Initial Complaint
10/19/2023
Complaint Type:
Service or Repair Issues
Status:
Answered
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
I submitted a reimbursemnent for the treatment for my dog ***** . ASPCA has wrongfully denied the claim stating that the To be eligible for coverage, this condition must be 180 days since its diagnosis, cure, and last treatment. This is not true . Last time ***** was seen for similar issue was on 9/26/21 which is more than 2 years ago. Please see *****s medical record attached. ASPCA has a track record of denying claims for no apparent reason. I need ASPCA to approve this claim and pay for my dogs treatment. ASPCA needs to be more ethical in its business practices.
Business response
10/30/2023
Dear **. ******:
We are in receipt of your October 19, 2023, inquiry relative to the above-mentioned policy holder regarding the Accident and Illness Policy (**********) for their dog. Per the Better Business Bureau direction, we have removed any reference that will personally identify our customer. The pet insurance policy is a personal lines property and casualty product filed under inland marine.
The customer enrolled their dog on the Accident and Illness Policy (**********) with an effective date of June 22, 2019. The policy subsequently renews on an annual basis.
In their inquiry, the customer expresses concern regarding coverage of a claim for submitted veterinary expenses. We subsequently received an appeal in our office on October 26, 2023, raising the same concerns. To aid in our review, additional medical history is required. As such, we sent a request for the required information per the customer’s signed authorization on the submitted claim form. Please also refer to the following excerpt from the customer’s insurance policy regarding authorization to request medical records:
Other Claim Procedures
When You submit a claim, You authorize Us and Our Administrator to access all medical information that We need to assess Your Pet's health. For example, we may ask you for the name and contact information of any Veterinarian that has ever seen or treated Your Pet.

You must also provide proof of identity for Your Pet when We request.

If You choose, Your Veterinarian can submit a claim on Your behalf. If You so indicate on Your claim form, We can pay the Veterinarian directly.

Payment of one claim does not guarantee that We will pay additional clai**.

Upon receipt of the required information, the claim will be reopened for further review and an appeal response with a detailed explanation will be provided directly to the customer.
We hope that the information provided in response to your inquiry is satisfactory. Thank you for the opportunity to respond to this matter. If you have any questions or need additional information, please contact me at 234-231-1771.
Sincerely,
****** ********
Compliance Analyst
ASPCA Pet Health Insurance
PTZ Insurance Agency, Ltd. (NPN #*******)
*********************
Initial Complaint
07/21/2023
Complaint Type:
Billing Issues
Status:
Answered
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
I purchased Pet Insurance from the ASPCA insurance company for my dog, Cloud, back in February of 2022. I recently decided to neuter my dog Cloud and I requested an estimate from my animal hospital for how much the neutering would be. The amount came out to $873.25. I sent the estimate in to ASPCA on May 9, 2023 and I received a letter back that stated they would pay $708.76 of the neutering and I would owe the other amount. I decided to move forward with the neutering and I paid $636.30, out of pocket, because ASPCA approved the estimate of $708.76. Meaning I was covered for the neutering costs. I sent ASPCA the invoice for the neutering and they started to give me the run around and tell me that I do not have the correct coverage. I did purchase the correct coverage but they changed my coverage from the Complete Coverage to Accident & Illness WITHOUT my permission. Please see attached for all of my proof
Business response
08/01/2023
Dear Ms. ******:

We are in receipt of your July 24, 2023, inquiry relative to the above-mentioned policy holder regarding the Accident and Illness Policy (PET-P-*****-****) for their dog. Per the Better Business Bureau direction, we have removed any reference that will personally identify our customer. The pet insurance policy is a personal lines property and casualty product filed under inland marine.

The complainant expresses concern regarding coverage for her dog’s neuter initially denied as ineligible preventive care not covered under the policy.

Upon receipt of the BBB complaint we reviewed the customer’s account and determined an error occurred. In light of the circumstances and in an effort to resolve the situation, we are reaching out to the customer directly to further discuss the matter. We apologize for any inconvenience.

We hope that the information provided in response to your inquiry is satisfactory. Thank you for the opportunity to respond to this matter.

Sincerely,

****** ********| Compliance Analyst
ASPCA Pet Health Insurance
PTZ Insurance Agency, Ltd. (NPN #*******)
*********************
Initial Complaint
06/07/2023
Complaint Type:
Billing Issues
Status:
Answered
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
I am filing this complaint against ASPCA Pet Health Insurance. I have an insurance policy with them for my dog, Elsa, who started limping some time ago. According to the medical records for my dog, the first time we brought her to the veterinarian was in June of 2022, at which time the Vet advised just to monitor her and that she may get better. She indeed got better, but then again around February of 2023 her limp suddenly got much worse. Since then, Vet prescribed rest, pain medication and abstinence from running. We followed his advice; however, my dog was not getting better. After few months of back and forth with the Vet, the Vet decided to do an X-ray and diagnosed our dog with broken ACL (anterior cruciate ligament) on May 16th, 2023. This was followed by surgery on May 21st, 2023. I have submitted a claim to my dog's insurance company, and they have approved only portion of the claim, stating that this falls under a CONTINUOS CARE, for which they provide up to 1000, - for the injuries from dating earlier from the date of insurance policy renewal date. My dog was not diagnosed with this injury (ACL) until May 16th 2023, so in my view, I see that the insurance is making an assumption that my dog had the same injury from June 2022, but there was no confirmed diagnostic from the Vet that our dog had an broken ACL (anterior cruciate ligament). This is a gray area, and I as a client, am left with having to paying the full bill. The Vet has repeatedly tried to spare our dog from the surgery, telling us that this is a very stressful procedure, and should be avoided if possible. I hereby request the full reimbursement from my insurance as per insurance policy (Allowed amount 2940,-) I would also like to tell you that this is the second time I am filing the same kind of complaint with you, against the same insurance, for the same dog, for the same type of injury, only on her left leg. Please see attached document for additional information.
Business response
06/14/2023
Dear Ms. ******:

We are in receipt of your June 7, 2023, inquiry relative to the above-mentioned policy holder regarding his Level 2 Accident and Illness Policy (*************) for his dog. Per the Better Business Bureau direction, we have removed any reference that will personally identify our customer.
The customer expressed concern regarding the amount of coverage for his dog’s right Anterior Cruciate Ligament (ACL) surgery.

The customer’s dog is enrolled on an Accident and Illness Policy (*************) with Continuing Care Amendatory Endorsement (**************) with an effective date of September 5, 2020. The Accident and Illness Policy has a 12 month Policy Period that is automatically reissued each year. The policy provides accident and illness coverage for eligible expenses incurred during the annual policy period. An annual incident limit of $3,000 applies per condition. Additionally, a $250 annual deductible and 90% co-insurance will be applied to covered expenses prior to reimbursement. The Continuing Care Amendatory Endorsement provides coverage for conditions which occur in one plan period and require continued treatment in subsequent plan periods. There is an incident limit of $1,000 that applies per condition and a lifetime limit of $2,500 that does not reset annually. These are separate from the base policy limits. Additionally, a $250 annual deductible and 90% co-insurance will be applied to covered expenses prior to reimbursement.

The customer submitted a claim for his dog’s right, torn ACL surgery performed on April 17, 2023. The claim for treatment of this condition was initially determined eligible for coverage under the Continuing Care Amendatory Endorsement where a total of $1,000 was reimbursed, satisfying the Continuing Care incident limit. This determination was based on medical records obtained at the time of processing noting the condition first showed signs or symptoms in June 2022, prior to the September 5, 2022 annual policy period. On June 28, 2022 records state, “P has been limping since week (Rt rear leg). Had ACL surgery last year on the left leg. Minimal right stifle DJD, likely secondary to cruciate ligament injury.”
Please refer to the applicable excerpts from the Accident and Illness Policy with Continuing Care Amendatory Endorsement as it relates to coverage.

3. WHAT IS NOT COVERED

3.1 Pre-Existing Conditions

We do not pay benefits for any charge that results directly or indirectly from a Pre-existing Condition that occurred on or before the Effective Date of the Policy. This exclusion applies to the Effective Date following initial enrollment, the Effective Date of a subsequent Reissuance, and the Effective Date resulting from a permissible midterm change in coverage resulting in a new Policy.

However, a Condition will no longer be considered pre-existing if 180 days have passed since Your Pet’s Condition was Cured and free from Treatment and Symptoms.

7.2 Coverage Termination at Reissuance
All coverage under the current policy ends on the last day of the Policy Period.
Pursuant to Section 3.1 Conditions that Occur during the current Policy Period are not eligible in subsequent Policy Periods unless the Continuing Care Endorsement is in effect for the current Policy Period and subsequent Policy Periods.
10. DEFINITIONS
Occur or Occurrence – When signs or symptoms related to a condition first become obvious, including when Your Pet first shows signs or symptoms related to a Condition that a Veterinary could have diagnosed or treated.
Policy Period – One year as specified on the declarations page
Pre-Existing Condition - Illness, disease, Injury or change to Your Pet's health that first Occurs or shows Symptoms:
a. before coverage is effective
b. during a Waiting Period
c. before the current Policy Period

This includes Conditions that are related to, secondary, or resultant from a Pre-Existing Condition.
Continuing Care Amendatory Endorsement

WHAT IS COVERED

Benefits for Accidents and Illnesses that are first eligible under Your base policy during the current Policy Period will continue to be eligible for benefit payment in the following Policy Periods. Coverage is allowed up to the maximum Continuing Care Incident and Lifetime Limits. These limits are separate from Your base policy limits. These limits will not reset at Reissuance.

Incident Limit: $1,000.00
Lifetime Limit: $2,500.00

Notwithstanding the above, upon further review the company has determined there is not a definitive link between the surgery performed on April 17, 2023 and the previous signs or symptoms noted in June 2022, prior to the September 5, 2022 effective date of the policy. As such, the claim will be reprocessed under the Accident and Illness Policy up to the $3,000 incident limit.
Thank you for the opportunity to respond to this matter. If you have any questions or need additional information, please contact me at 234-231-1771.
Sincerely,

****** ********* Compliance Analyst
C&F Insurance Agency (NPN # *******)
Crum & Forster Pet Insurance GroupTM| a Fairfax Company
*********************

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