Insurance Claim Reimbursement Rules

Summary

If an insurance company pays a claim not covered by the policy, they can still enforce the policy terms retroactively and demand repayment for any claims paid in error. If your pet hasnt been examined by a vet within the specified time frames, your policy will only cover accidents, not illnesses, and any illness premium will be refunded. If a claim includes both covered and non-covered conditions, the insurance company can divide the charge to calculate your reimbursement. If the insured has rights to recover any payment made under the policy, those rights are transferred to the insurer, and the insured must not impair them.

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Your Pet must have been examined by a Veterinarian in the twelve (*) months prior to the Pet Original Start Date as shown on the Schedule Page(s) or within fourteen (*) days after the Pet Original Start Date. Failure to do so will result in your policy defaulting to an Accident only policy. Meaning you will have PET00 (*/*) Page * of * AMERICAN MODERN HOME INSURANCE COMPANY Pet Health Insurance Policy no Illness Coverage and your Illness premium will be refunded.
This clause means that if your pet hasn't been examined by a vet in the specified time frames, your policy will only cover accidents, not illnesses. Any premium paid for illness coverage will be refunded.
In the event we reimburse a Claim contrary to the policy terms and conditions, this payment will not constitute a waiver of our rights to apply the terms and conditions retrospectively as they stand to any paid Claims or to any future Claims for that or any related condition.
This means that the insurance company maintains its right to apply the policy terms and conditions retrospectively even if they've paid a claim that contradicts them. They can also request repayment for any claims paid in error. They apply these conditions to all past and future claims.
In the event an Allowable Charge is for both covered and non-covered conditions, the Allowable Charge may be split into a covered and a non-covered Allowable Charge to calculate your Claim reimbursement.
This means if a claim includes charges for both covered and non-covered conditions, the insurance company can divide the charge accordingly to calculate your claim reimbursement. This ensures you only get reimbursed for the covered conditions.
If the insured has rights to recover all or part of any payment we have made under this policy, those rights are transferred to us. The insured must do nothing after loss to impair them. At our request, the insured will bring suit or transfer those rights to us and help us enforce them.
This means that if the insured has any right to recover part or all of the payment made under the policy, those rights are transferred to the insurer. The insured must not do anything to hinder these rights. If required, the insured must take legal action or transfer those rights to the insurer to help them enforce them.