Pet Insurance Benefit Schedules

Some pet insurance plans determine the amount of your claim refund using a benefit schedule. In some cases you might get back much less than you expect.

What is a benefit schedule?

The image below is an excerpt from Nationwide's Major Medical benefit schedule. The first column lists the specific diagnosis for your claim. The dollar figures in the columns to the right are the specific reimbursement amounts for each diagnosis code.

Actual Benefit Schedule Excerpt for a Diagnosis of Cardiomyopathy

In the example above, the total amount that you could be reimbursed for a primary diagnosis of cardiomyopathy is the sum of $835 plus $330, a total of $1,165.

Pros and Cons of Benefit Schedules

For the general case of benefit schedules in pet insurance, here are some pros and cons to the approach.

Pro #1: Easy to Disclose

Benefit schedules are easy to consolidate into a single document that can be attached to a policy and posted on a website.

Pro #2: Easy to Apply to Claims

If the benefit allowances are clearly laid out up front, pet parents can review the benefit schedule and see what their maximum payout will be for the year before they pay for expensive treatment. It can be harder to determine the coverage amounts if there are multiple diagnoses or no clear diagnoses, which happens more frequently than you might think.

Pro #3: Premiums May Be Lower

While some of the limitations of a benefit schedule reduce the claim payout (see cons below), lower reimbursements are generally reflected in lower pet insurance premiums. If you understand and accept the impact of the specific benefit schedule on your future claims payouts, lower premiums can be appealing.

Con #1: Not Indexed to Inflation

If the benefit schedule is not updated frequently, the reimbursement amounts can fall below current veterinary fees. According to the Bureau of Labor Statistics the average rate of veterinary inflation in metropolitan areas is around 6 - 7% per year. So if a procedure costs $1,000 this year then, on average, it will cost around $1,060 next year, then $1,124 the year after, and so on.

This gap between the cost of the actual procedure and the benefit schedule reimbursement amount will grow over time. This means you'll get a smaller and smaller percentage of each vet bill the longer it has been since an update.

Con #2: Specialist and Emergency Vet Fees

Specialist veterinary practices can cost a lot more than general practices. In the example above for cardiomyopathy, the benefit schedule will reimburse up to $531. But what if diagnosing and treating the cardiomyopathy cost $2,500?

In this scenario you would not get back more than $1,165 and you would have to pay 100% of any amount above the benefit schedule allowance, which adds to $2,500 - $1,165 = $1,335 in this case.

Con #3: Does Not Vary By Location

Veterinary costs typically vary a great deal depending on the location of the veterinary hospital. For example, according to a phone survey we did, a cruciate ligament repair in Williamsville, NY, costs about $2,600 versus $4,600 at a specialist clinic in Manhattan, NY. The current pet insurance benefit schedules do not vary by location, meaning that one cost applies to all locations across the US.

If the benefit schedule does not reflect geographic differences, the gap between the cost of the actual procedure and the benefit schedule reimbursement can be unexpectedly large if you did not check your benefit schedule in advance of paying for your treatment.


So, do the pros outweigh the cons? Depending on where you live and what kind of medical care you expect to give your pet should a future health concern happen, a benefit schedule might work for you; however, you need to fully understand the limitations when it comes to claim reimbursement to avoid disappointment. 

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Pet health insurance is administered by Embrace Pet Insurance Agency, LLC and underwritten by one of the licensed insurers of American Modern Insurance Group, Inc., including American Modern Home Insurance Company d/b/a in CA as American Modern Insurance Company (Lic. No 2222-8), and American Southern Home Insurance Company. Coverage is subject to policy terms, conditions, limitations, exclusions, underwriting review, and approval, and may not be available for all risks or in all states. Rates and discounts vary, are determined by many factors, and are subject to change. Wellness Rewards is offered as a supplementary, non-insurance benefit administered by Embrace Pet Insurance Agency in the United States. © 2016 American Modern Insurance Group, Inc.