ComplaintsforPTZ Insurance Agency, Ltd.

• Initial Complaint

  06/07/2023

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  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
  *********************

• Initial Complaint

  03/16/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  I got this pet insurance a couple years ago at about 60.00 a month. Accident and preventative. My cat had a broken tooth- took him to emergency vet, then when his vet was in - I made appt for tooth removal surgery. My insurance is for 70% coverage. After over 1300.00 in vet bills my insurance only covered 100.00! I believe they falsely advertise their insurance and rip people off! A broken tooth should be covered under his pet insurance!

  

  Business response

  03/10/2023

  Dear Customer Relations Representative:
  
  We are in receipt of your March 2, 2023, inquiry relative to the above-mentioned policy holder regarding her Accident and Illness Policy (****************) for her cat. 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. 
  
  The customer utilized our online enrollment center on April 23, 2020 to enroll her cat on a pet insurance policy with coverage for accidents and illnesses (****************) with Preventive Care Amendatory Endorsement (*****************) with an effective date of April 24, 2020.  The policy subsequently renews on an annual basis. The Accident and Illness Policy does not cover conditions that occur on or before the effective date of the policy.  Additionally, the customer elected our paperless option which authorizes us to provide communication via email, rather than mail. On April 24, 2020 we sent an email inviting the customer to our Member Center where a detailed explanation of the policy terms and conditions are available.
  
  The customer submitted claims for evaluation and treatment of her cat’s incurable Periodontal Disease. The related veterinary expenses were excluded from coverage as treatment of a pre-existing condition that did not meet the cured condition eligibility requirement.  This determination was made based on obtained medical records, which document the cat’s Periodontal Disease occurred in March 2020, prior to the April 24, 2020 effective date of the policy.  Further, there is no indication that any dental treatments were performed from the time of the initial diagnosis until the services rendered on the customer’s recently submitted claims.   Additionally, the customer states the extraction was for a broken tooth.  However, the medical notes do not support this statement. There is no mention of any broken teeth or any accident/injury documented in the records. The medical notes indicate the extraction was associated with periodontal disease (loose teeth, gingivitis).  The submitted veterinary expenses did include eligible reimbursement for an exam and dental cleaning up to the applicable limits of the Preventive Care Amendatory Endorsement.

  
  Please see below for applicable excerpts from the Accident and Illness Policy as it relates to pre-existing conditions. 
  
  DEFINITIONS 
  
  Condition - Illness, disease, injury or change to your pet's health that may or may not show symptoms or have been diagnosed (including but not limited to diagnosed or undiagnosed pre-existing, hereditary or congenital conditions, ligament and knee conditions).
  
  Occur or Occurrence – When signs or symptoms related to a condition first were observed by any individual or recorded in your pet's medical record, or would have been detectable by a routine physical veterinary exam.
  
  Pre-Existing Condition Illness means any condition for which a Veterinarian provided medical advice, the pet received treatment for, or the pet displayed signs or symptoms consistent with the stated condition prior to the effective date of a pet insurance policy or during any waiting period.
  
  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.
  
  Based upon the available information we have on file, our review indicates the claims were processed in accordance with the terms, conditions and exclusions of the Accident and Illness Policy. 
  
  Lastly, we respectfully disagree with the customer’s assertion that we are falsely advertising to our customers. Please note, we aim to present our policy terms and conditions in the most easy to understand, digestible, and clear manner. 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. 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
  PTZ Insurance Agency, Ltd. (*** ********)
  *********************

  Customer response

  03/10/2023

   
  Complaint: ********
  
  I am rejecting this response because:I have paperwork from Dec 2022 stating my cat had a loose tooth and he needed it pulled. I was given antibiotics, and the next dental was supposed to be March 2023.where my cat was going to get tooth pulled and teeth cleaned.

  The end of Jan2023 my cat was scratching at his mouth and drooling, he refused to eat and I took him to emergency vet. He was given antibiotics, and pain meds. This was another bill denied by my insurance!

  I was able to get my cat in to his regular vet, they opened a dental day in Feb. His loose tooth that his vet noted, had broken and slivers and roots were left. I’m sure my vets office would give this info freely- he went in for pre surgery bloodwork, and to have a tooth removed, as well as teeth cleaning. If this is In question the vets office can verify!

  a broken tooth should be covered under my insurance! I feel this is a total scam of people trying to care for their pets!also false advertising on insurance plans!

  I will be calling my vets office tomorrow to get copies of my cats records as proof Iam stating the full truth

  ***** *******
  
  Sincerely,
  
  ***** *******

  

  Business response

  03/16/2023

  Dear Ms. ******:
  
  We are in receipt of your March 16, 2023, inquiry relative to the above-mentioned policy holder regarding her Accident and Illness Policy (****************) for her cat. 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. 
  
  The customer utilized our online enrollment center on April 23, 2020 to enroll her cat on a pet insurance policy with coverage for accidents and illnesses (****************) with Preventive Care Amendatory Endorsement (*****************) with an effective date of April 24, 2020.  The policy subsequently renews on an annual basis. The Accident and Illness Policy does not cover conditions that occur on or before the effective date of the policy.  Additionally, the customer elected our paperless option which authorizes us to provide communication via email, rather than mail. On April 24, 2020 we sent an email inviting the customer to our Member Center where a detailed explanation of the policy terms and conditions are available.
  
  The customer submitted claims for evaluation and treatment of her cat’s incurable Periodontal Disease. The related veterinary expenses were excluded from coverage as treatment of a pre-existing condition that did not meet the cured condition eligibility requirement.  This determination was made based on obtained medical records, which document the cat’s Periodontal Disease occurred in March 2020, prior to the April 24, 2020 effective date of the policy.  Further, there is no indication that any dental treatments were performed from the time of the initial diagnosis until the services rendered on the customer’s recently submitted claims.   Additionally, the customer states the extraction was for a broken tooth.  However, the medical notes do not support this statement. There is no mention of any broken teeth or any accident/injury documented in the records. The medical notes indicate the extraction was associated with periodontal disease (loose teeth, gingivitis).  The submitted veterinary expenses did include eligible reimbursement for an exam and dental cleaning up to the applicable limits of the Preventive Care Amendatory Endorsement.
  Please see below for applicable excerpts from the Accident and Illness Policy as it relates to pre-existing conditions. 
  
  DEFINITIONS 
  
  Condition - Illness, disease, injury or change to your pet's health that may or may not show symptoms or have been diagnosed (including but not limited to diagnosed or undiagnosed pre-existing, hereditary or congenital conditions, ligament and knee conditions).
  
  Occur or Occurrence – When signs or symptoms related to a condition first were observed by any individual or recorded in your pet's medical record, or would have been detectable by a routine physical veterinary exam.
  
  Pre-Existing Condition Illness means any condition for which a Veterinarian provided medical advice, the pet received treatment for, or the pet displayed signs or symptoms consistent with the stated condition prior to the effective date of a pet insurance policy or during any waiting period.
  
  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.
  
  Based upon the available information we have on file, our review indicates the claims were processed in accordance with the terms, conditions and exclusions of the Accident and Illness Policy. 
  
  Lastly, we respectfully disagree with the customer’s assertion that we are falsely advertising to our customers. Please note, we aim to present our policy terms and conditions in the most easy to understand, digestible, and clear manner. 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. 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
  PTZ Insurance Agency, Ltd. (*** ********)
  *********************

  Customer response

  03/16/2023

   I am rejecting this response because:
  
  I have left a message for vet office, Will recieved paperwork showing he had a broken tooth removed! . I’d like to be reimbursed the 70%. A broken tooth is an accident - and should be covered by my plan.

• Initial Complaint

  03/07/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  I am on my second year of Accident + Colic insurance for my 4 horses, and also recently added coverage for my 2 cats. This is my very first claim. My horse recently sustained a bone chip that unfortunately became devitalized and turned into a sequestrum. Super straightforward accident/injury, right? Wrong, apparently. My claim for radiographs and antibiotics for this injury was denied, for reasons unknown. Garbage customer service. NOT happy.

  

  Business response

  03/17/2023

  Dear Ms. ******:

  We are in receipt of your March 7, 2023, inquiry relative to the above-mentioned policy holder regarding her Accident and Colic Policy (******************) for her horse. 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.

  Please be aware, after receiving this inquiry, we received a formal appeal in our office containing additional information.  Accordingly, we are further reviewing the account and verifying we are in receipt of all necessary medical information that we need to assess the health of the customer's horse.
  

  I will follow up early next week with the appropriate status update.
  

  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
  PTZ Insurance Agency, Ltd. (NPN #*******)
  *********************

• Initial Complaint

  03/07/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  On January 19th I had submitted a claim for my pet’s vet bill. The visit fell under the policy guidelines and all information including invoices, medical records, etc. was submitted with the claim. However, a month after consistently inquiring about my claim process it got denied for “not including an invoice.” After calling ASPCA and speaking to a representative she stated the invoice was in fact there. I have still not received payment for my claim and it has been almost 2 months since the incidence.

  

  Business response

  03/16/2023

  Dear Ms. Wimley:

  
  We are in receipt of your March 7, 2023, inquiry relative to the above-mentioned policy holder regarding her Accident and Illness Policy (****************) for her cat.  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 her cat on the Accident and Illness Policy (****************) with an effective date of March 2, 2021.  The policy subsequently renews on an annual basis.

  
  On January 20, 2023, we received a claim submission.  The original claim submission included only the first page of the invoice with a subtotal, however the second page of the invoice including proof of payment was not received.  Pursuant to the policy terms, it is a reimbursement policy wherein the customer is financially responsible to the veterinarian for services provided and we reimburse the actual costs for covered expenses the customer incurs during the policy period, after subtracting the deductible and co-insurance. Upon identifying the veterinary facility the pet had been to, we sent multiple requests for the required information.

  
  Subsequent emails were sent to the customer advising of the required documentation needed to properly assess the claim.  The claim was initially denied due to not receiving the complete invoice from the veterinary clinic.  While we were in receipt of a partial invoice, it was not the full documentation necessary to properly assess the claim.  Specifically, we require proof of payment to confirm the veterinary expenses were incurred. 

  
  Subsequent to this inquiry, we received a duplicate claim submission on March 7, 2023, which included a copy of the credit card receipt confirming payment of the subtotal of the invoice.  As such, the claim was processed under the new duplicate submission in accordance with the terms and conditions of the Accident and Illness policy (****************).  Accordingly, 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 to this matter.  If you have any questions or need additional information, please contact me at 234-231-1771. 

  
  Sincerely,
  
  ****** ******** Compliance Analyst
  PTZ Insurance Agency, Ltd. (NPN #*******)
  *********************

• Initial Complaint

  01/11/2023

  Complaint Type:

  Order Issues

  Status:

  Resolved

  More info

  I have been paying for medical insurance on my two cats since January of 2017. I have never used the insurance but I continue paying for it just in case. Even though I have not made any claims, my rates have continued to rise. Me fees were raised less then a year ago but now today I noticed that my fees went up yet again! This time by over $10 a month! I was never notified of this change. How can these criminals justify raising my rates multiple times a year, when I have not once filed a claim? These criminals have made thousands and thousands off of me but their selfish need to bleed us out of every single penny has over taken their original purpose. Which is to give us pet owners a piece of mind, by letting us keep "Affordable" insurance on the pets that we love and want to protect. The ***** and the insurance they provide through *** Insurance Agency, Ltd can not justify why they continue raising my rates, when I have never even used the insurance! I want (ALL) of my money back! I will use this money to find a better insurance company that won't feel the need to steal from me! I was never even notified of this huge rate hike! I can understand if the rate went up by a dollar or two but over $10, when it was already raised less then a year ago! That is criminal! At this rate these criminals will be charging me hundreds of dollars every month and they will raise it by hundreds every year!

  

  Business response

  01/23/2023

  Dear Ms. ******:

  
  We are in receipt of your January 11, 2023, inquiry relative to the above-mentioned policy holder regarding his Accident and Illness Policy (****************) for his cats.  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 concern regarding premium increases, specifically a premium increase for the January 5, 2023, Policy renewal.

  
  The customer’s cats were enrolled on the Accident and Illness Policy (****************) with an effective date of January 5, 2017. The policy renews on an annual basis. Please refer to the following excerpts from the Accident and Illness Policy as it relates to renewal.

  
  RENEWAL

  
  Unless you notify us that you want to cancel or we advise that your policy will not be renewed, we will automatically issue you a new policy at the end of each 12-month policy period. Coverage and rates are subject to change at renewal. Your renewal declarations page will specify the coverage and rates that apply. You accept these changes by renewing your policy.
  
  We may decide to not renew your coverage at the end of any policy period. In this case, at least 60 days before your coverage ends, we will mail written notice to you at your address as shown on the declarations page.
  
  Also, at the time of enrollment the customer elected our paperless option which authorizes us to provide communication via email, rather than mail. Accordingly, 60 days prior to reissuance, on November 1, 2022, we emailed the customer informing him of his renewal policy and welcoming him to log into our Member Center to see his renewal rates and coverage details. The available policy documentation included a cover letter as well as a copy of the Declarations page, providing a breakdown of the premium owed for the upcoming policy year. This allows the customer the opportunity to decide if the benefits of coverage live within her means. Additionally, it gives him an opportunity to contact us and discuss other potential coverage and pricing options. 
  
  Finally, we respectfully disagree with the customer’s assertion that we are conducting business criminally.  The customer was properly informed of the rates and coverage provided to him without misrepresentation or omission.  However, we are committed to further resolving the situation and will reach out to the policyholder.
  
  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   
  PTZ Insurance Agency, Ltd. (*** ********)   
  *********************
  

  Customer response

  01/23/2023

   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.

   

  My money was refunded. So I'm okay with the outcome. 

• Initial Complaint

  11/05/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  I have 2 annual pet insurance plans with this company. I have been submitting bills and being paid until today, October 15, 2022. I am unable to submit a claim either through their ASPCA pet insurance app, or online at aspcapetinsurance.com and I believe the phone numbers may have been disconnected. 1-866-204-6764 or Crum & Forsters Ins Agency 800-799-5852. They have been collecting monthly premiums of $140.37 and 59.94 for over 3 years. 1. Premiums I have paid since my last claim on 9/14 are as follows: 9/19 $140.37, 10/19 $140.37, 9/30 59.94, 10/30 59.94. 2. Are they still a business in good standing with an A+ rating? 3. They did not notify me they wouldn't be accessible to pay any more claims. 4. Now I can't have my dog covered by a new insurance company because his condition would be considered pre-existing. If I knew the company was shutting down, I would have purchased coverage for my dog in time. I would like the company to at least refund my premiums for 2022 and pay claims for which I paid.

  

  Business response

  11/15/2022

  Dear Ms. ******:
  
  We are in receipt of your November 5, 2022, inquiry relative to the above-mentioned policy holder regarding his Accident and Illness Policy (***************0) for his dogs. Per the Better Business Bureau direction, we have removed any reference that will personally identify our customer.  
  
  The customer expresses concern regarding claim submission as well as the current standing of the insurance company providing the insurance policy.  The customer’s dogs are enrolled on the Accident and Illness Policy (***************0).  The plan subsequently renews on an annual basis. Our records indicate the policies for both dogs are active and in good standing.

  
  The customer further mentions being unable to reach a representative via phone, however, this is due to the customer calling during non-business hours.  Our Customer Service Supervisor reached out to the customer on November 8, 2022, advising his policies are active, his claim submissions have been received and are under review and assured him our company is still in business.  Our Customer Service Supervisor further provided his direct contact information should the customer continue to have any questions or concerns.

  
  Accordingly, we consider this matter to be closed.  Thank you for the opportunity to respond.  If you have any questions or need additional information, please contact me at 234-231-1771.  

  
  Sincerely,

  
  ****** ********* Compliance Analyst
  PTZ Insurance Agency, Ltd. (NPN # *******)
  *********************
  
  

• Initial Complaint

  10/20/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  ASPCA pet insurance denied claims that they were covering for my dogs respiratory distress episodes that were related to low blood sugar. I had numerous Dr.s at ******************* Hospital write letters and talk to them personally because my dog was a complex case. They refused to listen to the Drs that were actually treating my dog over basic text book rather than treating this and understanding the complexity of my dogs medical issues. They were in fact paying this portion of claims after an appeal and review of talking with his medical team and then they decided to just stop. This condition was something that had the medical professionals at ********, which is one of the best veterinary schools in the country completely stumped as to why this was happening. Mostly because both his treatment and symptoms were ATYPICAL for pulmonic stenosis. That is why they agreed to pay this part of claims, then decided they would no longer after 2 trips to the ** a few weeks apart. They didnt cover any of his pulmonic stenosis related claims due to them being congenital, which is something they finally took out of their policy. The senior vet that was treating ****** had said that she had never seen this in her 30 yrs of experience, wrote a letter on my behalf and offered to discuss this and answer any questions they had. I was the one that figured out this may be a low blood sugar issue since he always seemed to have episodes before he was due to eat. His blood sugar was always low when admitted and his episodes got worse after the surgery which also proves its unrelated. As instructed, I started feeding him smaller frequent meals daily and before walks instead of after and he has not been admitted to the ** for this in over 3 years. They refused to listen to anything and would only make decisions based on text book and whoever they used to review claims and appeals that did not treat my dog. I fought with them for years on this. What they did was wrong!! I finally canceled

  

  Business response

  11/01/2022

  Dear ****************:
  
  We are in receipt of your October 20, 2022, inquiry relative to the above-mentioned policy holder regarding her Level 2 Accident and Illness Policy (BAS.2.2013) for her dog. Per the Better Business Bureau direction, we have removed any reference that will personally identify our customer.  

  
  The customers dog was enrolled on the Level 2 Plan (BAS.2.2013) with an effective date of January 1,2014.  The plan subsequently renews on an annual basis. The Level 2 Plan provides accident and illness coverage for eligible expenses incurred during the annual plan period. There is a $250 annual deductible, 20% co-insurance and an annual incident limit of $3,000.  The Level 2 Plan does not provide coverage for any congenital, hereditary, or genetic conditions or conditions which are related, secondary to, or the result of any congenital,hereditary, or genetic condition.

  
  The customer expresses concern regarding coverage of her dogs respiratory destress/collapse determined to be ineligible as a secondary condition to Pulmonic Stenosis, a hereditary,genetic and congenital condition.

  
  Prior to receipt of this inquiry, partial coverage was overturned via an appeal review for claims dated July 28, 2014 and July 5, 2014.  Based on this overturn, additional claims dated September 23, 2015 and November 27, 2016 were covered. Expenses associated with unspecified respiratory symptoms could not be definitively linked to a congenital heart condition based on the available medical records thus partial coverage was granted for workup of the respiratory distress, which was of unknown etiology at the time.
  

  The customer filed an additional appeal in 2018 following denial of another claim associated with congenital pulmonic stenosis, referencing our previous overturn and coverage of the respiratory distress. This additional review determined that the dogs respiratory distress symptoms which we previously overturned in 2014 were associated with the pulmonic stenosis and the owner was notified coverage would not be granted going forward.
  The owner expressed her position that the dogs respiratory episodes were due to hypoglycemia. However,respiratory distress is not a clinical sign associated with hypoglycemia.
  Provided with the customers policy documents issued each year since 2014 is a list of conditions we consider hereditary, genetic, and congenital and includes Pulmonic Stenosis.
  Please refer to the applicable excerpts from the Level 2 Plan (BAS.2.2013) as it relates to hereditary, genetic or congenital conditions.
  
  3.3 Policy Exclusions

  
  Unless covered by an applicable endorsement. We will not pay for expenses related to:

  
  b. any Hereditary, Genetic or Congenital Condition including those Conditions that are related, secondary, or resultant from any Hereditary, Genetic, or Congenital Condition.

  
  10. DEFINITIONS

  
  Hereditary, Genetic or Congenital Condition - Illness, defect, disorder or disease that is present from birth, inherited by Your Pet or to which Your Pet is predisposed through hereditary or genetic factors. A list of these conditions is available upon request and on Our website www.aspcapetinsurance.com.

  
  Per the customers request, coverage was cancelled effective October 27, 2020.

  
  Lastly, the customer requests a billing adjustment.  As the customer received the benefit of **********************, we are not able to accommodate this request.   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

  11/03/2022

   I am rejecting this response because:  Again, as stated numerous times and why I kept appealing this denial. After talking with doctors who actually treat my dog and not going by textbook which they tried to explain to you numerous times that my dog is a rare case and that treatment and symptoms for this issue were atypical of pulmonic stenosis. Diabetes and low blood sugar can definitely cause respiratory/breathing issues. Your body temperature can drop and make you cold and  Even in humans. It is rare but that is what they were trying to tell you. You were paying on these claims after speaking with his Drs initially. You refuse to accept the fact that this is not related to pulmonic stenosis and you keep trying to go by textbook and its not how my dogs medical issues are. ******** veterinary school is one of the best in the country. One *** Dr. ************ has been a cardiologist for over 25 years and has never seen this issue previously. They are not lying for me. They are trying to make you understand, by talking with you personally and writing letters on my behalf that this is not typical, but it is whats happening. From the beginning they knew some thing else was causing these issues but were unsure exactly what. Thats why you were paying the claims. You didnt want to pay the claims anymore because they kept happening and thats the real reason for the denials out of the blue. What you did was wrong I was a paying customer and this portion of his medical issues should have continued to be reimbursed. I want the last two claims submitted that were denied even with appeals paid to me because that is what I am owed. You say theres no relation to his blood sugar. Is it just completely ironic after changing his diet, meal times and frequency of meals he has not been admitted to the ** for another respiratory issue. No. Its because that is what was causing it. I stayed with your plan for 2 years trying to get this straightened. I canceled because you did me wrong because it was costing you too much. You got what you wanted, I canceled and you never have to worry about this anymore, but I should be paid what Im owed. This is not a text book situation and you refuse to accept that over money. My dog almost died numerous times. Thankfully after finally figuring out the root cause we are on the other side of this. But I wont stop fighting for what I am owed and for whats right. 
  
  
  

  

  Business response

  11/11/2022

  Dear ****************:
  
  We are in receipt of your November 3, 2022, inquiry relative to the above-mentioned policy holder regarding her Level 2 Accident and Illness Policy (BAS.2.2013) for her dog. Per the Better Business Bureau direction, we have removed any reference that will personally identify our customer.  
  

  The customers dog was enrolled on the Level 2 Plan (BAS.2.2013) with an effective date of January 1,2014.  The plan subsequently renews on an annual basis. The Level 2 Plan provides accident and illness coverage for eligible expenses incurred during the annual plan period. There is a $250 annual deductible, 20% co-insurance and an annual incident limit of $3,000.  The Level 2 Plan does not provide coverage for any congenital, hereditary, or genetic conditions or conditions which are related, secondary to, or the result of any congenital,hereditary, or genetic condition.
  

  The customer continues to express concern regarding coverage of her dogs respiratory destress/collapse.
  

  As stated in our previous response, the dogs respiratory distress symptoms were determined to be associated with an ineligible hereditary, genetic, and congenital condition, Pulmonic Stenosis.Provided with the customers policy documents issued each year since 2014 is a list of conditions we consider hereditary, genetic, and congenital and includes Pulmonic Stenosis.
  

  Please refer to the applicable excerpts from the Level 2 Plan (BAS.2.2013) as it relates to hereditary, genetic or congenital conditions.
  
  3.3 Policy Exclusions
  

  Unless covered by an applicable endorsement. We will not pay for expenses related to:
  

  b. any Hereditary, Genetic or Congenital Condition including those Conditions that are related, secondary, or resultant from any Hereditary, Genetic, or Congenital Condition.
  

  10. DEFINITIONS
  

  Hereditary, Genetic or Congenital Condition - Illness, defect, disorder or disease that is present from birth, inherited by Your Pet or to which Your Pet is predisposed through hereditary or genetic factors. A list of these conditions is available upon request and on Our website www.aspcapetinsurance.com.

  Notwithstanding the above, upon further review of the medical record and consultant reports the company has determined there is a question of fact as to whether the symptoms associated with Pulmonic Stenosis are the cause of the respiratory distress/collapse, such that we cannot definitively state the symptoms associated with Pulmonic Stenosis are indeed the cause of the respiratory distress/collapse.  As such, the related veterinary expenses have been reprocessed accordingly.  The customer will receive direct correspondence with a detailed explanation.
  

  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

  09/08/2022

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  Hello, My pet insurance is setting their own price that they would pay for services by pet's vet. My vet charges slightly higher fee than what the insurance was willing to pay, and I am left with having to pay the difference. I live in ******* area and I did not choose a price vet. I do not think this practice is fair. I am seeking for my insurance to refund me for the fill amount of the services rendered (minus the deductible as specified in our contract).

  

  Business response

  09/19/2022

  Dear Ms. ******:
  
  We are in receipt of your September 8, 2022, 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’s dog is enrolled on the Level 2 Plan **************) with Continuing Care Amendatory Endorsement (END.CCE.072011) with an effective date of September 5, 2016.  The plan subsequently renews on an annual basis. The Level 2 Plan provides accident and illness coverage for eligible expenses incurred during the annual plan period. There is a $250 annual deductible, 10% co-insurance and an annual incident limit of $3,000. 

  
  Reimbursement for eligible expenses is allowed in accordance with the usual and customary cost for the itemized service on the submitted invoice.  The customer’s concern is specifically directed at claims reimbursement that is based on usual and customary costs.  The practice of claims reimbursement being based on usual and customary costs is supported by the policy language for this product and is disclosed to customers prior to their enrollment.  Usual and customary costs are determined by using proprietary and industry data. 

  
  Upon receipt of this inquiry and further review of the customer’s account, the company determined necessary adjustments were warranted.  The applicable adjustments were applied accordingly and an additional reimbursement has been issued.  Outside of the necessary adjustments; the customer’s claims were processed in accordance with the terms, conditions and exclusions of the Level 2 Plan.  

  
  Lastly, the customer requests a refund.  As the customer is currently receiving the benefit of insurance, we are not able to accommodate this request.   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 (*** * *******)
  Crum & Forster Pet Insurance GroupTM| a Fairfax Company
  *********************

• Initial Complaint

  08/15/2022

  Complaint Type:

  Sales and Advertising Issues

  Status:

  Resolved

  More info

  My dog had a tumor growing on his lip which increased in size and affected his eating. Crum and Forester insurance agency denied my claim on no basis even though my plan covered accident or illness 90% past 250 deductible.

  

  Business response

  08/29/2022

  Dear Ms. ******:

  
  We are in receipt of your August 16, 2022, inquiry relative to the above-mentioned policy holder regarding her 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 pet insurance policy is a personal lines property and casualty product filed under inland marine.   

  
  The customer enrolled her dog on the Accident and Illness Policy (************) with an effective date of April 15, 2017.  The policy subsequently renews on an annual basis.

  
  On July 20, 2022, we received a claim submission.  To properly assess the claim, we required the dog’s medical history for the past year. Upon identifying the veterinary facilities the pet had been to, we sent multiple requests 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 claims.
  
  Subsequent emails were sent to the customer advising of the required medical records needed to properly assess the claims.  The claim was initially denied due to non-receipt of the required medical history.  While we were in receipt of partial medical records, it is not the full medical history necessary to properly assess the claims.  Specifically, we require medical records to confirm the onset of the pet’s tumor.  Upon receipt of the required information, the claim will be reopened and processed in accordance with the terms and conditions of the Accident and Illness policy (************).

  
  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
  C&F Insurance Agency (*** * *******)
  Crum & Forster Pet Insurance ******** * ******* *******
  *********************

  

  Business response

  09/06/2022

  Dear *** ******:

  
  We are in receipt of your August 30, 2022, 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 continues to express concern regarding coverage of a claim for treatment of his dog's growth.

  
  As stated in our previous response, the claim was initially denied due to non-receipt of the required medical history.  While we were in receipt of partial medical records, it was not the full medical history necessary to properly assess the claims.  Specifically, we require medical records to confirm the onset of the pet’s tumor.  On August 29, 2022, we received the required medical history to properly adjudicate the claim.  Accordingly, the claim was reopened and processed in accordance with the terms of the policy.  Eligible reimbursement was issued to the customer's ACH account on file on August 31, 2022.  As such, 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 to this matter.  If you have any questions or need additional information, please contact me at ************* 

  
  Sincerely,
  
  ****** ********* Compliance Analyst
  C&F Insurance Agency **** * ********
  Crum & Forster Pet Insurance ******** * ******* *******
  *********************

  Customer response

  09/07/2022

   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

  07/25/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  2022

  

  Business response

  08/04/2022

  Dear ****************:

  
  We are in receipt of your July 25, 2022,inquiry relative to the above-mentioned policy holder regarding her Accident and Illness Policy (BAS.2.2013) 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 customers dog was enrolled on the Accident and Illness Policy (BAS.2.2013) with an effective date of September 3,2016. The policy is reissued on an annual basis. Please refer to the following excerpts from the Accident and Illness Policy as it relates to reissuance.

  
  7.WHAT HAPPENS WHEN THIS POLICY IS REISSUED
  
  7.1 Automatic Annual Policy Reissuance
  
  Unless You notify Our Administrator that You want to cancel or We advise that Your policy will not be reissued, We will automatically issue You a new policy at the end of each 12-month Policy Period. Coverage and rates are subject to change at Reissuance. Your reissued declarations page will specify the coverage and rates that apply.
  
  We may decide to not reissue Your coverage at the end of any Policy Period. At least 60 days before Your coverage ends, We will mail written notice that Your policy will not be reissued to You at Your address as shown on the declarations page.
  
  The customer reached out to our *************************** on June 13, *************** she was informed her premium would be approximately sixteen dollars ($16.00).  Our representative explained an applicable premium increase and the mailing of her policy documents on an annual basis prior to reissuance. 
  
  Accordingly, 60 days prior to reissuance, on June 24, 2022, we mailed the customer her policy documents to the address on file.  The policy documentation included a cover letter as well as a copy of the Declarations page, providing a breakdown of the premium owed for the upcoming policy year.This will allow the customer the opportunity to decide if the benefits of coverage live within her means. Additionally, it gives her an opportunity to contact us and discuss other potential coverage and pricing options. 
  
  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
  C&F Insurance Agency (NPN # *******)
  **** & Forster Pet Insurance GroupTM| a Fairfax Company
  ***************************

  
  

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