Accident Only Pet Health Insurance

This policy has been written in readable language to help you understand its terms.

PLEASE READ YOUR POLICY CAREFULLY

Your policy is underwritten by American Modern Home Insurance Company, rated A+ by A.M. Best.

A stock insurance company Main Office Mailing Address: P.O. Box 5323 Cincinnati, Ohio 45201-5323

Embrace Pet Insurance Agency LLC

4530 Richmond Rd Cleveland, Ohio 44128

Your policy is fully administered by Embrace Pet Insurance Agency.

Insuring Agreement for Accident Only Policy:

We will provide the insurance described in this Accident Only policy in return for the premium and compliance with all applicable provisions and conditions of this policy.

The Declarations and Schedule Page show the:

a. Policy period

b. Coverages

c. Limits of liability; and

d. Premiums.

This policy is not complete without the Declarations and Schedule Pages.

Please note: This policy is for Accidents Only, it does not provide Coverage for any Illness at any time, even

if the Illness is:

a. Caused by;

b. Related to; or

c. An underlying condition of;

An Accident.

PART I – Definitions

In this policy, “you” and “your” refer to the Named Insured shown in the Declarations and the spouse, if a resident of the residence premises. “We”, “us”, and “our” refer to the Company providing this insurance. In addition, certain words and phrases are defined as follows:

Accident(s) means an unexpected or unintended event, which is specific as to place and time causing Injury to your Pet.
Aggression means an abnormal hostile response to an otherwise normal situation.
Allowable Charge(s) means the costs of the actual Treatment(s) provided by your Veterinary Provider.
Ambulance means a specialized land vehicle used for the sole purpose of transporting sick or injured Pets.
Annual Maximum is the maximum amount we will reimburse you per Pet in a period of insurance.
Bilateral Condition is a condition or disease the affects both sides of the body.
Chronic Condition is a detectable condition that, once developed, is deemed
1. a. Incurable; or
2. Likely to continue for the remainder of a Pet’s life.
Claim means your request for reimbursement of an amount under the terms of your policy for Treatment by a Veterinary Provider of your Pet.
Clinical Signs means changes in a Pet’s normal healthy state, bodily function or behavior observed by:
1. You;
2. A Veterinarian; or
3. Other observer.
Coverage is the insurance described in this policy.
Deductible is the annual amount you pay per Pet for Treatments covered by this policy before we will begin to reimburse you.
Illness means:
1. Sickness;
2. Disease; or
3. Any change in a Pet’s normal, healthy state.
Injury means:
1. Physical harm; or
2. Damage; To your Pet.
Medical Director means a Veterinarian who may be assigned by us to monitor and review:
1. The appropriateness of the services provided to the Pet;
2. The reasonableness of the fees; and
3. The relationship between conditions; As / if needed.
Medically Necessary means:
1. Directly; and
2. Materially; Related to a covered Injury, in our reasonable judgment.
Medication means any veterinary recommended items prescribed by your Veterinarian and approved by the Food and Drug Administration (FDA) of the United States or accepted for inclusion in the Homeopathic Pharmacopoeia of the United States for veterinary use. FDA‐approved or Homeopathic Pharmacopoeia‐included drugs available over the counter must be:
1. Dispensed directly by your Veterinarian; or
2. Compounded by a pharmacist under the guidance of your Veterinarian. Medication includes medical supplies required to administer those Medications.
Orthopedic means affecting or manifesting from the musculoskeletal system, which is made up of the body’s:
1. Bones (the skeleton);
2. Muscles;
3. Cartilage;
4. Tendons;
5. Ligaments; and
6. Joints including intervertebral spaces.
Policy Original Start Date means the effective date when you were first continuously covered by a policy administered by Embrace Pet Insurance Agency LLC, unless otherwise stated on the Schedule Page.
Pet is a:
1. Cat; or
2. Dog; Named and described in the Schedule Page(s) and both owned by you and residing with you.
Pet Original Start Date means the effective date when that Pet was first covered by a policy administered by Embrace Pet Insurance Agency LLC, unless otherwise stated on the Schedule Page.
Preventative Care means any:
1. Treatment;
2. Service; or
3. Procedure; Including but not limited to:
4. Physical examinations;
5. Medications;
6. Surgery;
7. Inoculations; or
8. Laboratory procedures; For the purpose of prevention of Injury or Illness or for the promotion of general health, where there has been no Injury or Illness.
Professional Services are:
1. Diagnosing;
2. Treating;
3. Operating; or
4. Prescribing; For any cat or dog Illness or Injury.
Pre‐existing Condition(s) means:
1. A Chronic Condition observed by you or your Veterinary Provider prior to the end of the Waiting Period for your Pet(s) and any related conditions; or
2. An Injury that first occurred or showed Clinical Signs prior to the end of the Waiting Period for your Pet and any related conditions.
3. Undiagnosed conditions with the same Clinical Signs as those in a. or b. above are also considered pre‐existing.
Reimbursement Percentage is the amount of the covered Allowable Charge for which you may be reimbursed.
Temporary Condition means an abnormal Clinical Sign or diagnosis, which is likely to resolve. A Temporary Condition may become a Chronic Condition.
Treatment means any:
1. Examination;
2. Consultation;
3. Hospitalization;
4. Anesthesia;
5. Surgery;
6. X‐rays, MRI or CT Scans;
7. Laboratory tests;
8. Nursing; or
9. Other care; Provided and administered by a Veterinary Provider.
Undiagnosed means the underlying or causative condition that has not yet been identified.
Veterinarian means a currently licensed Doctor of Veterinary Medicine.
Veterinary Provider means a:
1. Veterinarian;
2. Veterinary technician; or
3. Veterinary nurse; Currently licensed in the state in which Treatment is performed.
Waiting Period means the time period where the policy’s Coverage is restricted. For this policy, the time period is:
1. Two (2) days for Injuries; and
2. Six (6) months for Orthopedic Accidents for dogs. The Waiting Period starts from the Pet Original Start Date. Conditions that occur during the Waiting Period will be excluded from your policy’s Coverage as Pre‐existing Conditions. The Waiting Period also applies again when there are Coverage increases but is waived for policy renewals and optional Coverage renewals.

PART II – Conditions

We will pay covered veterinary expenses that you incur during the policy term for the diagnosis or Treatment of your Pet’s condition, up to the limits of this policy.

Your Pet must have been examined by a Veterinarian in the twelve (12) months prior to the Pet Original Start Date as shown on the Schedule Page(s) or within fourteen (14) days after the Pet Original Start Date. Failure to do so may result in your policy being voided. If your policy is voided, your premium will be refunded for the time your Pet was not covered. No Coverage is available until a qualifying Veterinarian has examined your Pet, and Pre‐existing Conditions, if any, may be determined upon the date of the qualifying Veterinarian’s examination.
The examining Veterinarian for the purposes of medical information or for an Orthopedic examination cannot be you or related to you.
All Treatment must be performed by a Veterinary Provider that you may freely choose.
You must arrange for a Veterinarian to examine and treat your Pet as soon as possible after it shows Clinical Signs of Injury.
You are financially responsible to your Veterinary Provider for payment of all Treatment.
Your Pet(s) must:
1. Reside with you; and
2. Be under your regular care and supervision; At the physical address ZIP Code listed on the Declarations Page.
By purchasing a policy, you give us permission to gather all medical history for your Pet(s) from alL your Veterinary Providers as we deem necessary. The medical information;
1. Must contain detailed Veterinarian examination findings; and
2. Must be made available for us to review; To satisfy the examination requirement in PART II. 1.
The standard Orthopedic condition Waiting Period for dogs is six (6) months from the Pet Original Start Date shown on the Schedule Page for that dog.
1. You may apply to reduce the Orthopedic Waiting Period by:
  1. Having a Veterinarian perform, at your own expense, an Orthopedic examination on your dog; and
  2. Submitting the results to us for review.
2. The Orthopedic examination must occur on or after the Pet Original Start Date for that dog and the Veterinarian must complete, sign and date the “Canine Orthopedic ExaminationReport” for based on that Orthopedic examination, which we shall supply upon request.Upon review of the results of the Orthopedic examination, we may reduce the OrthopedicWaiting Period for some or all Orthopedic conditions to two (2) days for Injuries, or fromthe Orthopedic examination date, whichever is later.
3. Our review of the Canine Orthopedic Examination Report only addresses the length of the Orthopedic Waiting Period. A comprehensive review of your dog’s medical information to determine Pre‐existing Conditions is not performed as part of this review and must be requested separately. Regardless of when the medical history is reviewed, any condition noted in the medical history prior to the end of the Orthopedic Waiting Period is a Pre‐existing Condition even if the condition is not noted on the Canine Orthopedic Examination Report form.

PART III – Coverage

IF SHOWN IN THE SCHEDULE PAGE(S), THE FOLLOWING COVERAGES APPLY SEPARATELY TO EACH PET.

Coverage: We will reimburse you for Allowable Charges in excess of the Deductible amount, subject to Reimbursement Percentage amounts, for Treatment(s) performed for conditions that occurred after the Waiting Period and during the policy period.
1. To qualify for reimbursement under this policy, the diagnosis must be an Accident per defined by this policy in PART I.1.
2. Accidents include but are not limited to:
  1. An automobile Accident;
  2. Ingestion of a foreign body;
  3. Poisoning;
  4. Animal bites;
  5. Gastric torsion; and
  6. Cruciate ligament rupture; As well as Accidents resulting in:
  7. Dental Trauma;
  8. Burns; and
  9. Fractures; (If shown as applicable on the Schedule Page(s)). Orthopedic Accidents are subject to the Orthopedic Waiting Period.
3. Accidental Orthopedic or dental fractures that occur or first show signs after the end of the Accident Waiting Period.
4. We will reimburse you for the costs of Medications your Veterinarian prescribes as part ofyour Pet’s Accident Treatment that started after the Waiting Period and during the policy period.
5. We will reimburse you for Pet Ambulance transport costs in the case of a medical emergency related to an Accident, by our best estimation. Coverage is up to the Annual Maximum as shown on the Schedule Page(s), subject to the Deductible and Reimbursement Percentage requirements.
Benefits: we will reimburse you for Medically Necessary Treatment, including tax, for:
1. Physical examination;
2. Surgery;
3. X‐rays, ultrasounds, and other diagnostic tests;
4. Professional Services rendered by your Veterinary Provider;
5. Medical supplies requires to perform covered procedures performed in the Veterinarian’s office and other medical supplies where deemed Medically Necessary by the Veterinarian, such as an Elizabethan collar;
6. Laboratory tests required by you Veterinary Provider;
7. Hospitalization required in order for your Veterinary Provider to deliver Professional Services to your Pet and post procedure in‐hospital care as is medically standard by our best estimation.
8. Medication that is prescribed by a Veterinary Provider;
9. Endodontic Treatment for tooth fractures, such as root canals and crowns, on the following teeth only:
  1. Molars;
  2. Upper 4th pre‐molars; and
  3. Canine teeth
10. Euthanasia where necessary for humane reasons resulting from an Accident;
Deductible and Reimbursement Percentage: Your Deductible is an annual amount. We will apply the Deductible to your Allowable Charges and then apply your Reimbursement Percentage to the remainder to determine your Claim reimbursement.

PART IV – Exclusions

Please read the following exclusion carefully. If an exclusion applies, we will not provide Coverage under this policy and you will not be reimbursed for any cost of Treatment you have paid for. We do not cover:

Any Illness;
Pre‐existing Conditions; In addition the following Injuries shall be considered Pre‐existing Conditions:
1. If your Pet has had Clinical Signs, prior to being insured, of a Bilateral Condition on one side of the body, she/he runs a higher risk of the same condition on the other side of the body and future occurrences of the same condition will not be covered. For example, but not limited to, if a dog has been diagnosed with a cruciate tear in his/her left leg before the end of the Orthopedic Waiting Period, a subsequent cruciate tear in his/her right leg shall be Pre‐existing.
2. Orthopedic Accidents occurring or showing Clinical Signs during the Orthopedic Waiting Period, even if the Accident Waiting Period is complete. For the purposes of these exclusions, Temporary Conditions that started prior to the end of the Waiting Period that have not shown any Clinical Signs for a period of twelve (12) consecutive months shall not be considered Pre‐existing Conditions.
Intervertebral disc disease is not covered by this policy, as it is a degenerative process, not an Accident. Though it can show signs suddenly and seem like an Accident, it is not covered as an Accident by this policy.
Treatments for Accidents arising from any Pre‐existing behavioral problems. For example, a dog that has persistently eaten rocks for foreign object prior to the Pet Original Start Date shall not be covered during the policy period for similar episodes.
More than the first submitted anesthetic removal of an ingested foreign body in one (1) period of insurance.
Any Illness as a result of a covered Accident that is not part of the initial course of Treatment for the Injury. For example, future Treatment(s) for liver damage from an Accidental poisoning or follow up joint rehabilitation for a cruciate ligament Injury are not covered by this policy.
The cost of boarding your Pet; including medical boarding.
Costs of Treatment(s) arising from your decision to pursue a course of Treatment other than that which was recommended you by your Veterinarian, unless specifically authorized by us prior to Treatment. Examples include:
1. Costs of Treatment(s) continued after a Veterinarian has recommended a Pet be euthanized for humane reasons;
2. Ignoring a Veterinarian’s recommendation to amputate a leg, resulting in extra costs associated with Treatment of gangrene;
3. Ignoring a Veterinarian’s recommendation to remove an eye, resulting in extra costs associated with chronic eye issues.
Treatment for any Injury deliberately caused by:
1. You;
2. Your family members;
3. Anyone living with you; or
4. Any other persons who have care, custody or control of your Pet.
Dental cleanings, even in the case of a dental Accident.
Treatment for Injury caused by deliberate endangerment of your Pet, such as organized fighting.
Treatment for Injury caused by persistent neglect of your Pet.
Cosmetic, aesthetic or elective surgery including:
1. Tail Docking;
2. Ear cropping;
3. De‐claw removal;
4. De‐clawing; or
5. Any other surgical procedure not related to an approved Injury.
Natural supplements, vitamins and all foods, whether prescribed or not, including, but not limited to:
1. Denamarin;
2. Glucosamine;
3. Probiotics;
4. Shampoo;
5. Conditioner; or
6. Ear cleaner.
Any administration fees charged by a Veterinary Provider or others, including chart set‐up fee or for providing information which may be required by us.
Professional fees and services performed by a Veterinary Provider for his/her own cat or dog.

PART V – Limits of Insurance

Regardless of the number of Claims made or covered Injuries that occur during the period of insurance, ourtotal liability for each period of insurance for all covered benefits shall not exceed the amounts shown on the Schedule Page(s) under Annual Maximum.

PART VI – Other Terms and Conditions

Paying Your Premiums: Your policy does not become legally binding until you have paid your premium. The premium is payable when you take out a new policy and when you renew an existing policy. Your policy is an annual contract of insurance with the option to pay annually or monthly. Premiums may increase at renewal for:
1. An Annual Maximum increase;
2. Age;
3. Veterinary cost inflation; and
4. Other actuarial changes. Premiums may also change during the policy term for changes in:
5. Your address;
6. Your Pet’s details; or
7. Other policy parameters. You must pay your premiums in full and on time to remain covered. Your policy will automatically renew at the end of your policy term unless you tell us otherwise or we non‐renew under rare circumstances.
Cancellation: You may cancel this policy at any time by:
1. Calling;
2. Emailing; or
3. Writing to us; and Stating the future date that you wish the cancellation to be effective. We may cancel this policy for any reason related to the acceptability of the risk at any time within the first sixty (60) days of the policy period. To cancel this policy, we will mail you a notice of cancellation to the named insured shown on the Declarations at the last known address shown in our records. If we cancel this policy within the first sixty (60) days after the effective date, notice of cancellation will be mailed at least thirty (30) days before the effective date of the cancellation. After this policy has been in effect for more than sixty (60) days, notice of cancellation due to any reason other than nonpayment of premium will be mailed at least sixty (60) days before the effective date of cancellation. If we cancel this policy at any time due to nonpayment of premium, notice of cancellation will be mailed at least fifteen (15) days before the effective date of the cancellation. After this policy is in effect for more than sixty (60) days, or if this is a renewal or continuation policy, we may only cancel for one or more of the following reasons:
4. You fail to pay your premium by the due date in accordance with the policy terms.
5. The policy was obtained through fraud, misrepresentation or concealment in your application, the content of which is specifically incorporated into and as a material term of this policy.
6. We have agreed to issue a new policy with the same or an affiliated company.
7. The Department of Insurance of the state governing the policy determines that a continuation of the policy could place us in violation of that state’s insurance laws.
8. You fail to comply with the policy terms and conditions in a manner that prejudices or negatively impacts our ability to properly assess or evaluation the Claim or other material rights we have under the policy.
9. Failure to provide us with information we have requested that is directly relevant to the Coverage provided under this policy or any Claim.
10. The use or threat of violence of aggressive behavior against our staff, contractors or property.
11. The repeated use of foul or abusive language. With respect to cancellation, this policy is neither severable or divisible. Any cancellation will be effective for all Coverage for all persons and all Pets. If this policy is cancelled, Coverage will not be provided as of the effective date of the cancellation shown on the notice of cancellation.
Cancellation Refund: Upon cancellation, you may be entitled to a premium refund. If you provide us notice of cancellation within thirty (30) days of the Original Start Date and you have made no Claim, we will refund the premium you paid us, and the policy will be cancelled. If you have made a Claim within thirty (30) days of the effective date, the premiums paid for or allocable to the first month of Coverage become fully earned upon the submittal of the Claim, and you will only receive a refund for any premiums paid for periods beyond the first month. After the first thirty (30) days of the policy period, we will compute any refund due on a daily pro‐rata basis based on the termination date of the policy.
Nonrenewal: If we decide not to renew or continue this policy, we will mail notice of nonrenewal to the named insured shown on the Declarations at the last known address appearing in our records. Notice, including the reason for nonrenewal, will be mailed at least sixty (60) days before the end of the policy period. Examples of reasons for nonrenewal include:
1. Failure to comply with terms and conditions;
2. Failure to provide medical records/relevant Claim information; or
3. Misrepresentation.
Misrepresentation, Concealment or Fraud: This policy is void in any case of:
1. Fraud;
2. Intentional concealment; or
3. Misrepresentation of a material fact; By you or any other insured, at any time, concerning:
4. This policy;
5. Your Pet;
6. Your interest in your Pet; or
7. A Claim under this policy.
Rights: 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. We reserve our right to recover from you any Claim reimbursement paid in error.
Splitting of Charges: 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.
Increasing Coverage: In the event you choose to increase your Pet’s Coverage, including lowering your Deductible, after the Original Pet Start Date, the Waiting Period and the determination of Pre‐existing Conditions reset as of the date of the Coverage change. There is no reset for a decrease in Coverage. We will automatically renew your policy at the expiration date unless you are otherwise notified of nonrenewal. We may change the
1. Premium;
2. Copay amounts;
3. Deductible; and
4. Policy terms and conditions; At renewal. You will be notified of changes in writing.
Allowable Charges Disputes: In the event that your Veterinary Provider charges an amount for Treatments in excess of those typically charged in your geographic area for identical Treatments or Professional Services or Treatments that are not Medically Necessary, we reserve the right to dispute the amount of the Allowable Charges to be reimbursed. Should we fail to resolve such disputes to your satisfaction, such disputes shall be resolved by means of the procedures listed in PART VII – Claims, Appeals and Complaints of the policy.
Promotional Offers Insurance: Each named insured may occasionally receive promotional offers,nwhich include but are not limited to gift cards, coupons, gift certificates and items of merchandise. The maximum value of any promotional item will not exceed $25.00.
Other Insurance Coverage: If at any time a Claim arises under this insurance and there is other insurance providing Coverage to the insured’s Pet, this policy shall be deemed to be excess insurance. The policy will only respond to any:
1. Claim;
2. Costs; or
3. Expenses; Once all other valid and collectible insurance has been exhausted, and then only for the excess amount not covered by said other insurance, subject always to the Terms and Conditions of this policy. It is your responsibility to notify us in the event that other insurance is in place. Failure to do so may be considered concealment and may render Coverage provided under this policy null and void and all outstanding Claims shall be forfeited and not paid. You are responsible for submitting an explanation of benefits for any other insurance Coverage with your Claim to us for consideration.
Transfer of Rights of Recovery Against Others to Us: 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.
Joint and Individual Interests: If there is more than one named insured on this policy, any named insured may cancel or change this policy. The action of one named insured shall be binding on all persons afforded Coverage under this policy.
Transfer: This policy may not be transferred to another person without our written consent. This Coverage is not transferable to other Pets.
Period of Insurance and Territory: This policy applies only to Injuries occurring during the policy period shown on the Declarations and which occur anywhere in the world.
Electronic Delivery: By accepting the terms of this insurance as evidenced by the payment of premiums, it is agreed, unless otherwise notified by you, all:
1. Documents;
2. Notices; and
3. Communications; Regarding this policy, other than documents required to be delivered by another method, may be delivered to you by electronic mail using the email associated with your account. It is further agreed that it is your responsibility to keep your contact details including email address current and correct.
Conformity to State Statutes: When this policy’s provisions are in conflict with the statutes of the state in which this policy is used, the terms and conditions are amended to conform to such statutes.

PART VII – Claims, Appeals and Complaints

How to file a Claim: Contact Information

Embrace Pet Insurance Claims Department PO Box 22188 Beachwood, OH 44122‐0188 Phone: 800‐511‐9172 Fax: 800‐238‐1042 Upload: MyEmbrace Portal, Start A Claim Email: Claims@embracepetinsurance.com

Claim Procedure: Any Claim you make will be assessed fairly, reasonably and promptly against the information you provide and the terms of the policy.
1. All Claims must be submitted and received by us within sixty (60) calendar days after the next policy renewal date after the date of the Claim’s veterinary Allowable Charges.
2. You must send us a Claim form that has been properly completed. We will then write to you with our decision.
3. We will not guarantee on the phone if we will cover a Claim.
4. All Claims must be submitted on the Claim form that we email you with your policy documents.
5. You may also download the Claims for from our web site or print it at your Veterinary Provider’s office. You may also ask us to mail you a Claim form.
6. You must provide all itemized invoices from your Veterinary Provider along with your completed Claim form before we will reimburse you. Save the originals in case we require them from you.
7. You must cooperate with us in the investigation or settlement of the Claim. An Explanation of Benefits form will be available to you, which shows how we determined the amount to reimburse you for your Claim. The following describes the appeal process in the event you are not satisfied with the way we have handled your Claim, or you are not happy with your policy. All requests for an appeal must be submitted to us within ninety (90) days of the finalization of your Claim. You may contact us using the information below.

Procedure:

First Appeal: Once we receive your formal appeal or complaint, we will contact you within five (5) working days to tell you what we are doing about it. We will provide a final determination with reasoning to you within two (2) weeks. If it takes us longer than two (2) weeks to complete our review, we will tell you when you can expect an answer.
Second Appeal: If you disagree with our decision in the first appeal, you may request further appeal via an external review. A request for a second appeal must be made within thirty (30) days of the date of issuance of your first appeal decision to you. An impartial veterinarian selected by Embrace:
1. Who is independent of Embrace and the insured;
2. Who is not controlled by us; and
3. Who has not been part of your Pet’s veterinary team previously; Will conduct an external review of:
4. The medical records;
5. Any letters submitted for appeal by your Veterinarian; and
6. Questions posed by Embrace; Concerning Coverage of the condition. Embrace will provide the decision to the insured within three (3) working days of receiving the independent Veterinarian’s report. This process may take up to thirty (30) days.
Complaints: If you disagree with the decision made at any time during the appeal process, you have the right to file a complaint with your State Department of Insurance. Please refer to your individual state’s department for details and applicable rules and laws.

Contact Information Embrace Pet Insurance Claim Appeals Department PO Box 22188 Beachwood, OH 44122‐0188 Phone: 800‐511‐9172 Fax: 800‐238‐1042 Email: Claims@embracepetinsurance.com

The Company has caused this policy to be signed by the President and Secretary. It is countersigned on the Declarations Page by our authorized representative(s) if required.

The signature of the Secretary and President for the Accident Only Terms and Conditions document.