NAIC Pet Insurance Model Law

NAIC Model Laws, Regulations, Guidelines and Other Resources—Summer 2022

PET INSURANCE MODEL ACT

Table of Contents

Section 1. Short Title

Section 2. Scope and Purpose

Section 3. Definitions

Section 4. Disclosures

Section 5. Policy Conditions

Section 6. Sales Practice for Wellness Programs

Section 7. Insurance Producer Training

Section 8. Regulations

Section 9. Violations

Section 1. Short Title

This Act shall be known as the “Pet Insurance Act.”

Section 2. Scope and Purpose

A. The purpose of this Act is to promote the public welfare by creating a comprehensive legal framework within

which Pet Insurance may be sold in this state.

B. The requirements of this Act shall apply to Pet Insurance policies that are issued to any resident of this state,

and are sold, solicited, negotiated, or offered in this state, and policies or certificates that are delivered or

issued for delivery in this state.

C. All other applicable provisions of this state’s insurance laws shall continue to apply to Pet Insurance except

that the specific provisions of this Act shall supersede any general provisions of law that would otherwise be

applicable to Pet Insurance.

Section 3. Definitions

If a pet insurer uses any of the terms in this Act in a policy of pet insurance, the pet insurer shall use the definition of each of

those terms as set forth herein and include the definition of the term(s) in the policy. The pet insurer shall also make the

definition available through a clear and conspicuous link on the main page of the pet insurer or pet insurer’s program

administrator’s website.

Nothing in this Act shall in any way prohibit or limit the types of exclusions pet insurers may use in their policies or require

pet insurers to have any of the limitations or exclusions defined below.

As used in this Act:

A. “Chronic condition” means a condition that can be treated or managed, but not cured.

B. “Congenital anomaly or disorder” means a condition that is present from birth, whether inherited or caused

by the environment, which may cause or contribute to illness or disease.

C. “Hereditary disorder” means an abnormality that is genetically transmitted from parent to offspring and may

cause illness or disease.

D. “Orthopedic” refers to conditions affecting the bones, skeletal muscle, cartilage, tendons, ligaments, and

joints. It includes, but is not limited to, elbow dysplasia, hip dysplasia, intervertebral disc degeneration,

patellar luxation, and ruptured cranial cruciate ligaments. It does not include cancers or metabolic,

hemopoietic, or autoimmune diseases.

E. “Pet insurance” means a property insurance policy that provides coverage for accidents and illnesses of pets.

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F. “Preexisting condition” means any condition for which any of the following are true prior to the effective

date of a pet insurance policy or during any waiting period:

(1) A veterinarian provided medical advice;

(2) The pet received previous treatment; or

(3) Based on information from verifiable sources, the pet had signs or symptoms directly related to the

condition for which a claim is being made.

A condition for which coverage is afforded on a policy cannot be considered a preexisting condition on any

renewal of the policy.

G. “Renewal” means to issue and deliver at the end of an insurance policy period a policy which supersedes a

policy previously issued and delivered by the same pet insurer or affiliated pet insurer and which provides

types and limits of coverage substantially similar to those contained in the policy being superseded.

H. “Veterinarian” means an individual who holds a valid license to practice veterinary medicine from the

appropriate licensing entity in the jurisdiction in which he or she practices.

I. “Veterinary expenses” means the costs associated with medical advice, diagnosis, care, or treatment provided

by a veterinarian, including, but not limited to, the cost of drugs prescribed by a veterinarian.

J. “Waiting period” means the period of time specified in a pet insurance policy that is required to transpire

before some or all of the coverage in the policy can begin. Waiting periods may not be applied to renewals

of existing coverage.

K. “Wellness program” means a subscription or reimbursement-based program that is separate from an

insurance policy that provides goods and services to promote the general health, safety, or wellbeing of the

pet. If any wellness program [insert language from state statute or regulation that defines the trigger for

insurance contracts, which might include language such as: [undertakes to indemnify another], or [pays a

specified amount upon determinable contingencies] or [provides coverage for a fortuitous event]], it is

transacting in the business of insurance and is subject to the insurance code. This definition is not intended

to classify a contract directly between a service provider and a pet owner that only involves the two parties

as being “the business of insurance,” unless other indications of insurance also exist.

Section 4. Disclosures

A. A pet insurer transacting pet insurance shall disclose the following to consumers:

(1) If the policy excludes coverage due to any of the following:

(a) A preexisting condition;

(b) A hereditary disorder;

(d) A chronic condition.

(2) If the policy includes any other exclusions, the following statement: “Other exclusions may apply.

Please refer to the exclusions section of the policy for more information.”

(3) Any policy provision that limits coverage through a waiting or affiliation period, a deductible,

coinsurance, or an annual or lifetime policy limit.

(4) Whether the pet insurer reduces coverage or increases premiums based on the insured’s claim

history, the age of the covered pet or a change in the geographic location of the insured.

NAIC Model Laws, Regulations, Guidelines and Other Resources—Summer 2022

(5) If the underwriting company differs from the brand name used to market and sell the product.

B. Right to Examine and Return the Policy.

(1) Unless the insured has filed a claim under the pet insurance policy, pet insurance applicants shall

have the right to examine and return the policy, certificate or rider to the company or an

agent/insurance producer of the company within fifteen (15) days of its receipt and to have the

premium refunded if, after examination of the policy, certificate or rider, the applicant is not satisfied

for any reason,

(2) Pet insurance policies, certificates and riders shall have a notice prominently printed on the first

page or attached thereto including specific instructions to accomplish a return. The following free

look statement or language substantially similar shall be included:

“You have 15 days from the day you receive this policy, certificate or rider to review it and return it to the

company if you decide not to keep it. You do not have to tell the company why you are returning it. If you

decide not to keep it, simply return it to the company at its administrative office or you may return it to the

agent/insurance producer that you bought it from as long as you have not filed a claim. You must return it

within 15 days of the day you first received it. The company will refund the full amount of any premium paid

within 30 days after it receives the returned policy, certificate, or rider. The premium refund will be sent

directly to the person who paid it. The policy, certificate or rider will be void as if it had never been issued.”

C. A pet insurer shall clearly disclose a summary description of the basis or formula on which the pet insurer

determines claim payments under a pet insurance policy within the policy, prior to policy issuance and

through a clear and conspicuous link on the main page of the pet insurer or pet insurer’s program

administrator’s website.

D. A pet insurer that uses a benefit schedule to determine claim payment under a pet insurance policy shall do

both of the following:

(1) Clearly disclose the applicable benefit schedule in the policy.

(2) Disclose all benefit schedules used by the pet insurer under its pet insurance policies through a clear

and conspicuous link on the main page of the pet insurer or pet insurer’s program administrator’s

website.

E. A pet insurer that determines claim payments under a pet insurance policy based on usual and customary

fees, or any other reimbursement limitation based on prevailing veterinary service provider charges, shall do

both of the following:

(1) Include a usual and customary fee limitation provision in the policy that clearly describes the pet

insurer’s basis for determining usual and customary fees and how that basis is applied in calculating

claim payments.

(2) Disclose the pet insurer’s basis for determining usual and customary fees through a clear and

conspicuous link on the main page of the pet insurer or pet insurer’s program administrator’s

website.

F. If any medical examination by a licensed veterinarian is required to effectuate coverage, the pet insurer shall

clearly and conspicuously disclose the required aspects of the examination prior to purchase and disclose that

examination documentation may result in a preexisting condition exclusion.

G. Waiting periods and the requirements applicable to them, must be clearly and prominently disclosed to

consumers prior to the policy purchase.

H. The pet insurer shall include a summary of all policy provisions required in Subsections (A) through (G),

inclusive, in a separate document titled “Insurer Disclosure of Important Policy Provisions.”

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I. The pet insurer shall post the “Insurer Disclosure of Important Policy Provisions” document required in

Subsection (H) through a clear and conspicuous link on the main page of the pet insurer or pet insurer’s

program administrator’s website.

J. In connection with the issuance of a new pet insurance policy, the pet insurer shall provide the consumer

with a copy of the “Insurer Disclosure of Important Policy Provisions” document required pursuant to

Subsection (H) in at least 12-point type when it delivers the policy.

K. At the time a pet insurance policy is issued or delivered to a policyholder, the pet insurer shall include a

written disclosure with the following information, printed in 12-point boldface type:

(1) The [insert state insurance department]’s mailing address, toll-free telephone number and website

address.

(2) The address and customer service telephone number of the pet insurer or the agent or broker of

record.

(3) If the policy was issued or delivered by an agent or broker, a statement advising the policyholder to

contact the broker or agent for assistance.

L. The disclosures required in this section shall be in addition to any other disclosure requirements required by

law or regulation.

Section 5. 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 Subsection 5B 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.

(a) A medical examination under Subsection 5B(1) shall be paid for by 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 Subsection 5B.

(2) Waiting periods, and the requirements applicable to them, must be clearly and prominently disclosed

to consumers prior to the policy purchase.

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.

NAIC Model Laws, Regulations, Guidelines and Other Resources—Summer 2022

Section 6. Sales Practices for Wellness Programs

A. A pet insurer and/or producer shall not do the following:

(1) Market a wellness program as pet insurance;

(2) Market a wellness program during the sale, solicitation, or negotiation of pet insurance.

B. If a wellness program is sold by a pet insurer and/or producer:

(1) The purchase of the wellness program shall not be a requirement to the purchase of pet insurance.

(2) The costs of the wellness program shall be separate and identifiable from any pet insurance policy

sold by a pet insurer and/or producer.

(3) The terms and conditions for the wellness program shall be separate from any pet insurance policy

sold by a pet insurer and/or producer.

(4) The products or coverages available through the wellness program shall not duplicate products or

coverages available through the pet insurance policy; and

(5) The advertising of the wellness program shall not be misleading and shall be in accordance with

Subsection 6B of this Model.

(6) A pet insurer and/or producer shall clearly disclose the following to consumers, printed in 12-point

boldface type:

(a) That wellness programs are not insurance.

(b) The address and customer service telephone number of the pet insurer or producer or

broker of record.

website address.

C. Coverages included in the pet insurance policy contract described as “wellness” benefits are insurance.

Section 7. Insurance Producer Training

A. An insurance producer shall not sell, solicit, or negotiate a pet insurance product until after the producer is

appropriately licensed and has completed the required training identified in Subsection C of this Section.

B. Insurers shall ensure that its producers are trained under Subsection C of this Section and that its producers

have been appropriately trained on the coverages and conditions of its pet insurance products.

C. The training required under this subsection shall include information on the following topics:

(1) Preexisting conditions and waiting periods;

(2) The differences between pet insurance and noninsurance wellness programs;

(3) Hereditary disorders,

congenital anomalies or disorders and chronic conditions and how pet

insurance policies interact with those conditions or disorders; and

(4) Rating, underwriting, renewal and other related administrative topics.

D. The satisfaction of the training requirements of another state that are substantially similar to the provisions

of Subsection C shall be deemed to satisfy the training requirements in this state.

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Section 8. Regulations

The commissioner may promulgate rules and regulations to administer this Act.

Section 9. Violations

Violations of this Act shall be subject to penalties pursuant to [insert state administrative code].

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Chronological Summary of Action (all references are to the Proceedings of the NAIC).

Summer 2022 (adopted).