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Why is this treatment for something my horse has had not covered by the insurance?

I wrote a blog post similar to this awhile back. Horse insurance is different from the medical insurance we get for ourselves. The biggest way it is different is that it only covers an injury, lameness, accident, sickness or disease that "occurred or commenced" or "first occurring, first sustaining, first contracting or first manifesting itself" or "first sustained, first occurs or first manifests" during the policy period (taken from the 3 carriers I use most often).

What does that mean? It means the policy is designed to cover unexpected injuries or conditions (why is my horse lame this morning? how did he find the only loose fence screw in the entire pasture and cut his hip open? why did she get a cough & snotty nose right before our event this weekend?). It means that if you know your horse has something they shouldn't normally have prior to you getting insurance and you don't disclose it, if you seek treatment later, the condition will likely be found to be pre-existing. If you find something during your first year policy and you don't report it to the carrier but you seek treatment during your second policy term, the condition could be found to be pre-existing. If you find something during your first policy year that your vet says just to watch for any changes and then you seek treatment for it during a renewal policy, it could be found to be pre-existing.

While the subsequent policy terms are called renewals, you really need to think of them in terms of single year policies that do not carry anything over from year to year. Each new business policy and subsequent renewals typically exclude any condition that has not been cured before that policy takes effect. The policy is not intended to cover anything that you know about that might result in a future claim or any condition that cannot be cured (arthritis is a good example of this - we know a horse with arthritis can be maintained for it's use, but the insurance company will not pay claims related to the arthritis because it is not curable).

That being said, not everything results in an exclusion. Underwriting evaluates whether they feel it needs to be excluded. If it's not excluded and there is a later claim, then the claims adjustor is going to look at the previous notes and the current information from the vet in making a determination if the condition can be considered to have commenced or manifested during this policy period or if it will be considered pre-existing.

Exclusions on a policy suck - that's true whether it be home insurance, auto insurance, business insurance, or equine insurance But they are on a policy to manage your expectations of what will be covered. So if your horse has something abnormal that your vet doesn't feel needs to be treated right away, report it with your renewal application anyways. Provide ample information that your vet is saying it's nothing to worry about unless it changes. If the underwriting department decides it will be excluded, then you don't have the expectation that will be covered in the future if it does change. If underwriting doesn't exclude it, you have an appeal with a claims adjustor if they deny it as pre-existing because you can show you reported it and your vet didn't think it needed to be treated but now the condition has changed so the change is new to this policy period. You may not be successful in that appeal, but you have a better shot than if the company never heard about the condition before. And depending on the company, failure to have disclosed previously could be considered a misrepresentation on the application. For example, Hartford's and Great American's new business and renewal applications ask if the horse has been EXAMINED or treated by a vet for other than routine care - so if the vet noticed something off, they were examined for something not routine even if that came during a routine exam. American Reliable asks it the same way on their new business application, but their renewal application only asks about examination or treatment for specific things. However, the policy language still only covers things that first occur during the renewal policy.

The good news is, if you and/or your vet can be specific with the condition, the insurance company tries to be specific with the exclusion. If the description of the injury is the horse is sore in the right stifle and right hock, the exclusion is likely going to be any abnormal condition of the right hind limb. But, it doesn't have to be that way. For example, I have a horse that had a very bad laceration to his foot (basically he tried to pull his hoof off). The insurance covered the medical claim because clearly it had not been that way when I renewed it. But at the following renewal, the hoof had not completely healed. I explained in detail the injury and the current state of healing, and as I expected there was an exclusion. The next renewal, the injury had completely healed except that in one spot on the coronary band, the damage causes the hoof to have a cosmetic defect in the way it grows. Because that injury caused something that is permanent, they could not remove the exclusion despite the horse being fully sound. However, my exclusion still reads "lacerations along coronary band with hoof wall fractures - right rear". So if that cosmetic defect ever weakens and causes a problem, it is not a covered claim because the defect arose out of the hoof wall laceration and/or the coronary band laceration. But if the horse does anything new (knock on wood) to that same right hind hoof, that will be covered - but I'm sure I'm going to have to show some evidence that the new condition is new and not related to the old injury.

In short, it is incumbent on you to report new conditions with your application so the company can give you an idea if they will be excluded or not. Not reporting them because you don't want to turn in a claim or because it doesn't need treated now does not change the policy language when you have a claim. And if you ever are not sure, ask your agent. They are your advocate and don't want to see you surprised or upset if a claim is not covered.


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