Policy Conditions

Policy Conditions A. A pet insurer may issue policies that exclude coverage on the basis of one or more preexisting conditions with appropriate disclosure to the consumer. The pet insurer has the burden of proving that the preexisting condition exclusion applies to the condition for which a claim is being made. B. A pet insurer may issue policies that impose waiting periods upon effectuation of the policy that do not exceed 30 days for illnesses or orthopedic conditions not resulting from an accident. Waiting periods for accidents are prohibited. (1) A pet insurer utilizing a waiting period permitted in Rule 6.04(B) must issue coverage to be effective by 12:01 a.m. on the second calendar day after purchase, subject only to the following exceptions: (a) If an insurer elects to conduct individualized underwriting on a specific pet, then coverage must be effective by 12:01 a.m. on the second calendar day after the insurer has determined such pet is eligible for coverage. (b) Any insurer may delay coverage from becoming effective to establish a method for the consumer or group administrator to pay the premium, or (c) For pet insurance coverage acquired by an individual through an employer or organization, the coverage requirements of the employer’s or organization’s benefit plan. (d) If a policy does not include a waiting period for an illness or orthopedic condition, an insurer may set a policy effectuation date that is up to fifteen (15) calendar days after purchase, so long as such policy effectuation date is clearly disclosed and no premium is charged before the policy becomes effective. (2) A pet insurer utilizing a waiting period permitted in Rule 6.04(B) shall include a provision in its contract that allows the waiting periods to be waived upon completion of a medical examination. Pet insurers may require the examination to be conducted by a licensed veterinarian after the purchase of the policy. (3) Waiting periods, and the requirements applicable to them, must be clearly and prominently disclosed to consumers prior to the policy purchase (a) A medical examination under Rule 6.04(B)(1) shall be paid for the policyholder, unless the policy specifies that the pet insurer will pay for the examination. (b) A pet insurer can specify elements to be included as part of the examination and require documentation thereof, provided the specifications do not unreasonably restrict a consumer’s ability to waive the waiting periods in Rule 6.04(B). C. A pet insurer must not require a veterinary examination of the covered pet for the insured to have their policy renewed. D. If a pet insurer includes any prescriptive, wellness, or non-insurance benefits in the policy form, then it is made part of the policy contract and must follow all applicable laws and regulations in the insurance code. E. An insured’s eligibility to purchase a pet insurance policy must not be based on participation, or lack of participation, in a separate wellness program.