7.03 million pets insured in 2024. Pre-existing condition denials are the #1 complaint. In 14 states with NAIC Model Act protections, the burden is on the insurer to prove your pet's condition existed before coverage started.
2024
12.2% increase from 2023
Trupanion
Highest 2024 payout
Claimants
With reimbursement process
NAIC Act
Strong consumer protections
Estimate your appeal success rate and potential recovery based on denial reason, state protections, and veterinary support.
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The pet insurance industry grew to 7.03 million insured pets by the end of 2024, a 12.2% jump from 6.25 million in 2023. Trupanion alone has paid over $3 billion in veterinary bills since 2000, with their highest single claim in 2024 reaching $76,974.21. Healthy Paws pet parents spent an estimated $588 million on accident or illness veterinary care in 2024.
Despite this massive growth, claim denials remain a major frustration for pet owners. The three most common complaints are: (1) long waits for claims reimbursement, (2) denial of claims for pre-existing conditions, and (3) premium increases. A 2023 veterinary survey found that if a bill exceeds $1,145, the average pet owner cannot afford to proceed with treatment. This makes insurance claim denials particularly devastating when families face bills for gastrointestinal obstructions ($6,500 average) or cancer diagnoses ($9,000+).
Good news: 80% of pet owners who filed claims were satisfied with the reimbursement process, suggesting most legitimate claims do get paid. And in the 14 states that have adopted the NAIC Pet Insurance Model Act (including California, Ohio, Pennsylvania, Maryland, Louisiana, and New Hampshire), consumer protections are significantly stronger. The Model Act shifts the burden of proof to the insurer when they claim a pre-existing condition, requires clear disclosure of waiting periods and benefit schedules, and mandates training for insurance producers.
The Problem: Most pet insurance policies do not cover pre-existing conditions. A pre-existing condition is typically defined as any injury or illness contracted, manifested, diagnosed, or treated before the policy took effect or during applicable waiting periods.
Aggressive Denials: Some insurers (particularly Embrace, according to consumer complaints) are issuing denials for pre-existing conditions with little or no merit. They may argue that two conditions are connected even if diagnosed years apart. For example, a 2022 ear infection might be cited as a reason to deny a 2024 cancer claim, claiming both are "immune system issues."
NAIC Model Act Protection: In the 14 states with NAIC Model Act protections, the law explicitly limits how insurers can deny pet insurance claims related to pre-existing conditions. The onus is on the insurer to prove that the pre-existing condition limitation applies. This is a major shift from standard states where the burden is on the pet owner.
Your Rights: Request complete medical records from your vet and the insurer. Look for the exact date of first symptoms, first diagnosis, and policy effective date + waiting period. If symptoms appeared during the waiting period but diagnosis came after, some policies still cover it. Get a detailed letter from your vet stating the condition was NOT pre-existing.
The Issue: Pet insurance policies have waiting periods before coverage begins. Standard waiting periods are: Accident (0-14 days), Illness (14 days), Orthopedic conditions (6-12 months), and Cruciate ligament conditions (6-12 months).
If your pet shows symptoms during the waiting period, the insurer may deny the claim even if treatment occurred after the waiting period ended. However, if your vet confirms the condition was an acute onset (sudden illness) rather than a chronic condition, you have a strong appeal case (75% success rate with veterinary support).
Action: Document exact dates. Policy effective date, waiting period end date, first symptom date, first vet visit, diagnosis date, treatment date.
The Issue: Some policies have annual limits ($5,000-$30,000/year) or benefit schedules (maximum amount per diagnosis). If you've reached your annual limit or the condition exceeds the benefit schedule amount, your claim will be denied for any excess charges.
Options: File new claims in the next policy year. Some providers allow mid-year policy upgrades to higher limits. Healthy Paws and some other providers have no annual or lifetime limits, which is better for high-dollar claims.
Read Your Policy: Check if you have an "annual limit" plan vs "unlimited" plan. Review benefit schedules carefully.
The Issue: This is the most easily reversible denial (85% success rate). Insurers may deny claims for "insufficient documentation" or "incomplete medical records."
Solution: Contact your vet immediately and request complete records: all vet visits, diagnosis notes, treatment plans, lab results, x-rays, and invoices. Resubmit the claim with complete documentation. Most denials for incomplete records are resolved by simple resubmission.
The Issue: Standard processing time for pet insurance claims is 7-14 days, though some insurers can take up to 30 days. If you haven't received a response beyond 30 days, this may constitute bad faith.
Action: Follow up in writing. Send a certified letter requesting status update. If no response within 30 days total, file a complaint with your state insurance commissioner. Many states require "prompt" claim responses under insurance bad faith laws.
The National Association of Insurance Commissioners (NAIC) adopted the Pet Insurance Model Act at its Summer 2022 National Meeting. This model law establishes regulatory standards for the pet insurance industry, addressing pet wellness programs, pre-existing conditions, consumer protections, and training for insurance producers.
Despite being freely available, only 14 states have adopted similar legislation as of 2024.
Law: California Insurance Code 12880-12880.6 (amended 2024)
California was the only state with laws specifically governing pet insurance before the NAIC Model Act. In 2024, California amended its pet insurance regulations to add language from the NAIC model act, expanding on definitions and adding more consumer protections.
Key Protection: Burden on insurer to prove pre-existing condition. File complaints with California Department of Insurance.
Effective: Late January 2024
Ohio adopted pet insurance laws based on the NAIC model in the summer of 2024, which took effect in late January. This includes pre-existing condition protections, required disclosures, and clear differentiation of wellness programs from insurance.
Effective: December 2024
Pennsylvania passed a bill based on the NAIC model in June 2024, and it took effect in December. Strong consumer protections for claim denials and pre-existing condition disputes.
Effective: Late 2024
Maryland adopted legislation based on the NAIC model in late 2024, with the state House and Senate passing the law unanimously. Full NAIC protections including burden on insurer for pre-existing condition claims.
Effective: January 1, 2024
Louisiana legislators amended the state's crop and livestock insurance statute to adopt the NAIC model in 2023, with the law taking effect on Jan. 1, 2024.
Effective: August 2023
New Hampshire Governor signed pet insurance standards into law in August 2023, based on NAIC Model Act protections.
Illinois, Michigan, Connecticut, Florida, Texas, New York, Colorado, and Washington have also adopted NAIC Model Act protections with varying effective dates and implementation details.
Check your state insurance commissioner website for specific regulations.
If your state has not adopted the NAIC Model Act, you have weaker consumer protections. Pet insurance is regulated under general insurance laws, which may not address pet-specific issues.
Important: The burden of proof for pre-existing conditions is typically on YOU (the pet owner) in non-NAIC states. You must prove the condition did NOT exist before coverage started.
Most pet insurance companies offer reimbursement rates of 70%, 80%, or 90%, though some providers offer rates ranging from 50% to 100%. The standard reimbursement rate in the industry is between 80% and 90%.
Reimbursements are based on your actual veterinary bill. The insurer determines the total of the covered treatments and multiplies that by your reimbursement rate.
Example: $5,000 vet bill × 80% reimbursement = $4,000 reimbursement (you pay $1,000)
A benefit schedule is a list of diagnoses with the maximum amount that a pet insurance plan will pay. Any costs exceeding the outlined amount are paid out of pocket.
Example: Cancer treatment bill $9,500 but benefit schedule caps cancer at $5,000 → you pay $4,500 out of pocket
Some insurers reimburse based on "usual and customary" fees in your geographic area, not your actual bill. If your vet charges above the regional average, you may pay the difference even with 90% reimbursement.
Most pet insurers process reimbursements within 7 to 14 days after receiving your complete claim. Some insurers can take up to 30 days. If you haven't received payment or a response after 30 days, follow up in writing and file a complaint with your state insurance commissioner.
If your claim is denied, don't give up. Rejected pet insurance claims can often be overturned. Follow these steps to appeal your denial:
Action: Carefully read the denial letter. Look for the specific reason for denial: pre-existing condition, waiting period, exclusion, benefit limit, incomplete records, etc.
Cross-Reference: Pull out your policy documents and cross-reference the denial reason with your policy terms. Look for the exact policy language cited by the insurer.
Red Flags: If the denial letter is vague, doesn't cite specific policy language, or uses generic phrases like "not medically necessary," this may be a weak denial that's easily overturned.
⏰ TIME SENSITIVE: Many policies require appeals within 14 days of the denial date. Check your denial letter and policy for the exact deadline.
Required Documents:
Create a Timeline: Make a clear timeline showing all relevant dates. This is critical for pre-existing condition and waiting period denials.
Request a Letter: Ask your veterinarian to write a detailed letter supporting your appeal. This is especially important for pre-existing condition denials.
What the Letter Should Say:
✅ Success Rate: Appeals with veterinarian support have 25% higher success rates. For pre-existing condition denials in NAIC states, vet letters increase success from 45% to 70%.
Format: Send a certified letter (return receipt requested) or use the insurer's online appeal portal if available.
Appeal Letter Template:
[Your Name]
[Your Address]
[Date]
[Insurance Company Name]
Claims Department
[Insurance Address]
Re: Formal Appeal of Claim Denial - Claim #[CLAIM NUMBER] - Policy #[POLICY NUMBER]
Dear Claims Manager,
I am writing to formally appeal the denial of my pet insurance claim dated [DENIAL DATE] for [PET NAME]'s [CONDITION/TREATMENT]. Your denial letter stated the reason as [QUOTE EXACT DENIAL REASON].
I believe this denial is incorrect for the following reasons:
1. [Your first argument with supporting evidence]
2. [Your second argument with supporting evidence]
3. [State law protections if applicable - e.g., "Under California Insurance Code 12880.6, the burden is on the insurer to prove pre-existing condition"]
Enclosed, please find:
- Complete medical records from [VET NAME]
- Letter from [VET NAME] confirming [KEY FACT]
- Timeline of policy effective date vs symptom/diagnosis dates
- [Other supporting documents]
I request that you reconsider this claim and approve reimbursement of $[AMOUNT] per my policy terms ([REIMBURSEMENT RATE]% reimbursement).
Please respond within 14 days. If this appeal is denied, please provide a detailed written explanation citing specific policy language.
Sincerely,
[Your Signature]
[Your Name]
Keep Copies: Keep copies of everything you send. Use certified mail with return receipt so you have proof of delivery.
If No Response After 14 Days: Send a follow-up letter and email. Many policies require a response within 14-30 days.
If Appeal is Denied Again:
💡 Industry Data: 80% of pet insurance claimants are satisfied with the reimbursement process. If you're in the 20% with a denial, persistence pays off - many denials are overturned on appeal, especially with proper documentation and vet support.
If your pet insurance company denies a legitimate claim without a reasonable basis, or delays payment unreasonably, you may have grounds for a bad faith insurance lawsuit. Bad faith claims allow you to recover not just the original claim amount, but also additional damages including emotional distress, attorney fees, and punitive damages.
Insurance bad faith occurs when an insurer fails to deal fairly and in good faith with policyholders. To win in a bad faith case, you must show that:
Law: Fla. Stat. 624.155(1)
Florida law states that any person may bring a civil action against an insurer when they suffer damages because of an insurer not acting in good faith to settle a claim. Florida bad faith claims can result in damages beyond the original claim amount, including consequential damages, emotional distress, and attorney fees.
Consult a Florida pet insurance claim lawyer if your claim was unreasonably denied.
Law: California Insurance Code 12880-12880.6 + Common Law Bad Faith
California has both statutory protections for pet insurance and common law bad faith remedies. Insurers have an implied covenant of good faith and fair dealing. Unreasonable denial or delay can result in tort damages including emotional distress and punitive damages.
File complaints with California Department of Insurance and consider legal action for bad faith.
Most states recognize insurance bad faith claims under common law or statute. Examples of bad faith include: unreasonable denial of valid claims, failure to investigate claims properly, misrepresenting policy terms, unreasonable delays in processing claims (beyond 30 days with no valid reason), and failure to communicate with policyholders.
Consider consulting a pet insurance bad faith attorney if:
Bad faith lawsuits can recover the original claim amount PLUS additional damages, attorney fees, and punitive damages. Fighting claim denials can be tough, but legal action may be worthwhile for high-dollar or clearly wrongful denials.
Pre-existing conditions are the #1 reason for pet insurance claim denials. A pre-existing condition is defined as any injury or illness contracted, manifested, diagnosed, or treated before the policy took effect or during applicable waiting periods.
Insurers may aggressively deny claims by arguing that a current condition is related to a past condition, even if the connection is questionable (e.g., claiming a 2024 cancer diagnosis is related to a 2022 ear infection because both involve "the immune system").
Protection in NAIC States: In the 14 states that adopted the NAIC Pet Insurance Model Act (California, Ohio, Pennsylvania, Maryland, Louisiana, New Hampshire, Illinois, Michigan, Connecticut, Florida, Texas, New York, Colorado, Washington), the burden is on the insurer to prove the pre-existing condition. This significantly strengthens your appeal chances.
What to Do: Request complete medical records from your vet and the insurer. Create a timeline showing: policy effective date, waiting period end date, first symptom date, first vet visit, diagnosis date. If symptoms appeared during the waiting period but diagnosis came after, some policies still cover it. Get a letter from your vet stating the condition was NOT pre-existing.
Standard processing time: Most pet insurers process reimbursements within 7 to 14 daysafter receiving your complete claim. Some insurers can take up to 30 days depending on claim complexity.
Faster Options: Some providers (like Trupanion) offer direct payment to veterinarians at the time of service, eliminating the need for you to pay upfront and wait for reimbursement. However, this requires your vet to be enrolled in the program.
Delays Beyond 30 Days: If you haven't received payment or a response after 30 days, this may constitute bad faith. Follow up in writing via certified mail. File a complaint with your state insurance commissioner. Many states require "prompt" claim responses under insurance bad faith laws.
Industry Data: 80% of pet insurance claimants report satisfaction with the reimbursement process, suggesting most claims are paid within the standard timeframe.
The National Association of Insurance Commissioners (NAIC) Pet Insurance Model Act was adopted at the NAIC Summer 2022 National Meeting. This model law establishes regulatory standards for the pet insurance industry, addressing pet wellness programs, pre-existing conditions, consumer protections, and training for insurance producers.
Key Consumer Protections:
States That Adopted the NAIC Model Act (14 total as of 2024):
Non-NAIC States (36 states): If your state has not adopted the NAIC Model Act, you have weaker consumer protections. Pet insurance is regulated under general insurance laws. The burden of proof for pre-existing conditions is typically on YOU (the pet owner).
Yes, you can sue your pet insurance company for bad faith if they denied your claim without a reasonable basis and knew (or should have known) the denial was unreasonable.
Requirements for Bad Faith Lawsuit:
Examples of Bad Faith:
State Laws:
When to Consult an Attorney: Consider legal action if your claim is substantial (over $5,000), the denial is clearly unreasonable, the insurer ignored your evidence, or you suffered significant emotional distress or financial hardship. Bad faith lawsuits can recover the original claim amount PLUS additional damages, attorney fees, and punitive damages.
Warning: Fighting claim denials can be tough. Many pet insurers have watertight terms and conditions, and lengthy legal battles can cost more than the initial treatment. Weigh the costs vs benefits before pursuing litigation.
Standard reimbursement rates: Most pet insurance companies offer reimbursement rates of 70%, 80%, or 90%, though some providers offer rates ranging from 50% to 100%. The industry standard is between 80% and 90%.
How It Works: After you meet your deductible, your pet insurance provider will pay back a percentage of your veterinary bills, which is your reimbursement rate.
Example Calculation:
Calculation Methods: Insurers use 3 different methods to calculate reimbursements:
Higher Reimbursement = Higher Premiums: A policy with 90% reimbursement will have higher monthly premiums than 70% reimbursement. Choose based on your budget and willingness to pay out-of-pocket costs.
Industry Statistics (2024):
Common Treatment Costs:
Overall Pet Care Spending: The American Pet Products Association (APPA) estimates pet parents will spend$150.6 billion on overall pet care in 2024, a 2.4% increase from 2023.
Is Pet Insurance Worth It? With 80% satisfaction rate among claimants and claims averaging 50% more than annual premiums, pet insurance can provide significant value for unexpected veterinary bills. However, read policy terms carefully to understand pre-existing condition exclusions, waiting periods, and annual limits.
5-Step Appeal Process:
Success Rates by Denial Reason:
Based on consumer complaints and legal references:
Embrace Pet Insurance: Law firms are frequently seeing denials by Embrace for "pre-existing conditions," and Embrace seems to be issuing denials with little or no merit. Multiple complaints suggest aggressive denial practices.
Trupanion: While Trupanion has paid over $3 billion cumulative and processes the highest-dollar claims ($76,974 highest 2024 claim, 2,310 claims over $10,000 in 2024), they also have complaints for strict enforcement of pre-existing condition exclusions.
Industry-Wide Issues: The three most common complaints across all pet insurers are:
Good News: 80% of pet owners who filed claims were satisfied with the reimbursement process, suggesting most legitimate claims do get paid. If you're in the 20% with a denial, use the appeal process outlined above.
Where to File Complaints:
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