Your horse has a swollen hock. X-rays show an OCD chip (bone fragment). The vet wants to scope it out. Cost: $3,500. You file a claim. The insurer denies it, citing “Pre-Existing” or “Congenital” exclusions, or simply that it’s an “Elective” procedure.
Key Takeaways
- Developmental Defects: OCD chips are often considered developmental. If the horse is young, some policies cover it. If the horse is older, they might argue it was pre-existing but asymptomatic.
- Lameness Requirement: Insurance covers surgery to treat illness or injury. If the horse is not lame, and you just want to remove the chip to sell him, that is “Elective” and excluded.
- Surgical Endorsement: Does your policy limit surgery to “Life Saving” (colic) or include “Orthopedic”?
- Co-Pay: Orthopedic surgery usually carries a 20% co-pay.
The “Why” (The Trap): Elective vs. Necessary
Insurers don’t pay for “maintenance” or “cosmetic” surgery.
The Trap: The vet says, “We should take this chip out before it causes trouble.”
The Insurer: “So it’s not causing trouble now? Denied. Not medically necessary.”
The Investigation: The Claim Language
I reviewed the definition of “Medical Necessity.”
- To get paid: The vet notes must state: “Horse is Grade 3 lame. Chip is the cause. Surgery required to return to function.”
- To get denied: The notes state: “Chip found on pre-purchase exam. Horse sound. Removing to improve resale value.”
Comparison Table: Surgical Types
| Procedure | Coverage Status | Notes |
| Colic Surgery | Covered | Life Saving |
| Fracture Repair | Covered | Injury |
| OCD Removal (Lame) | Covered | Must prove lameness |
| OCD Removal (Sound) | Denied | Elective |
| Neurectomy (Nerving) | Denied | Unethical/Performance altering |
[IMAGE: X-ray of a hock showing a bone chip]
Step-by-Step Action Plan
- Lameness Exam First: Before scheduling surgery, have the vet document the lameness exam.
- Pre-Auth: Call the adjuster. “My horse is lame. Vet recommends arthroscopy.” Get approval in writing.
- Check Waiting Periods: If you just bought the policy 30 days ago, there might be a waiting period for non-emergency surgery.
- Understand the Limit: Some policies have a sub-limit (e.g., $5,000) for orthopedic surgery, even if the main medical limit is $10,000.
FAQ
Does insurance cover the MRI to find the chip?
Major Medical usually covers diagnostics ($1,500 – $2,500 limit). Surgical Only does not.