Benefit Schedules or Benefit Limits

If you are considering purchasing pet health insurance and the provider uses something called a "Benefit Schedule" or "Benefit Limits" you'd better have a vet or an accountant in the family to help you figure it out. I am a vet and the policy I looked at this morning was really hard for me to understand. 

A "Benefit Schedule" is a listing of literally hundreds of conditions and diseases that might befall your pet and the diagnostic procedures that your vet might use to figure out what's going on. Not only that, but there is a five column chart with each listing that further modifies the potential benefit. Some insurers use these tables to determine how much you might be reimbursed on a given claim. Oh, and there are two "benefit schedules" one for each plan and one pays less than the other.

 

Besides the obvious level of complexity this entails, what are the other possible issues with a "benefit schedule"?

 

What if your vet charges more than the"benefit schedule" allows? This is an easy answer. You get to pay the difference, plus, in this case, your per incident deductible and copay. 

 

Is this a big deal? Well, consider this. According to a National Commission on Veterinary Economic Issues report from last year, over the last ten years, veterinary fees have risen at twice the rate of inflation as measured by the consumer price index. That "benefit schedule" better be revised at least yearly to keep up or it will quickly be out of date. Ask that question before you buy.

 

What about the cost of veterinary care in your town or city? Veterinary fees vary tremendously across the country and yet the "benefit schedule" I looked at was one size fits all. Now that might be great for me in rural South West New Mexico, but what if I lived in Albuquerque? Heck, what if I had the misfortune to live in LA or New York? One size does not fit all.

 

How do we deal with these issues at PurinaCare? The answer is very simple. After you have met your deductible, we pay 80% of covered expenses. That's 80% of covered expenses in Podunk, New Mexico and 80% of covered expenses in Downtown, New York City. 

 

We use the term "usual and customary" for veterinary fees and here's what we mean by that in plain english: We'll pay the going rate in your area.

 

We know that fees vary in the same area and in our interpretation there is enough latitude to cover the local variation in fees. If there is a case where we think the fees charged on the claim are way out of line we'll look into it. 

 

How often would that happen? Not very often. In fact, we have not disputed one single claim on the basis of "usual and customary" since we opened our doors.