An inguinal hernia is a defect in the opening from the abdomen down to the testicular sac and obesity sometimes can change something miniscule and not noticeable into a serious condition that needs surgery to fix the defect.
Details of the claim for Roxy, a 1 year old Dachshund living in Pomona CA:
| DATE | ITEM | Tax | BILLED AMOUNT | COVERAGE TYPE | COVERED IN POLICY? | COVERED CHARGES |
| 11/7/2009 | Examination | $ 42.00 | IL | Y | $ 42.00 | |
| 11/7/2009 | Radiograph Abdomen | $ 159.44 | IL | Y | $ 159.44 | |
| 11/7/2009 | Chem 5 (5-6 Tests) | $ 60.70 | IL | Y | $ 60.70 | |
| 11/7/2009 | Total Body Function | $ 143.00 | IL | Y | $ 143.00 | |
| 11/7/2009 | Ova/Par-G 1 yr | $ 53.00 | IL | Y | $ 53.00 | |
| 11/7/2009 | Fluid Therapy Set Up | $ 92.40 | IL | Y | $ 92.40 | |
| 11/7/2009 | Fluid 1st Bag | $ 0.00 | IL | Y | $ 0.00 | |
| 11/7/2009 | IV Catheter | $ 0.00 | IL | Y | $ 0.00 | |
| 11/7/2009 | IV Administration Set | $ 0.00 | IL | Y | $ 0.00 | |
| 11/7/2009 | Fluid Pump | $ 18.95 | IL | Y | $ 18.95 | |
| 11/7/2009 | Hospitalization | $ 77.00 | IL | Y | $ 77.00 | |
| 11/7/2009 | Occupancy | $ 0.00 | IL | Y | $ 0.00 | |
| 11/7/2009 | Nursing Care | $ 0.00 | IL | Y | $ 0.00 | |
| 11/7/2009 | Prof Care | $ 0.00 | IL | Y | $ 0.00 | |
| 11/7/2009 | Intensive Care Level 1 | $ 15.45 | IL | Y | $ 15.45 | |
| 11/7/2009 | Exam Pre-Anesthesia | $ 0.00 | IL | Y | $ 0.00 | |
| 11/7/2009 | Preanesthes/Induction | $ 57.85 | IL | Y | $ 57.85 | |
| 11/7/2009 | Gen Anes 1st 1/2 hr | $ 118.60 | IL | Y | $ 118.60 | |
| 11/7/2009 | Gen Anes Add. 15 min | $ 53.30 | IL | Y | $ 53.30 | |
| 11/7/2009 | Anes Monitoring Lv 2 | $ 63.20 | IL | Y | $ 63.20 | |
| 11/7/2009 | Hernia -Inguinal | $ 494.35 | IL | Y | $ 494.35 | |
| 11/7/2009 | Nursing/Injections | $ 59.00 | IL | Y | $ 59.00 | |
| 11/7/2009 | Ampicillin | $ 19.48 | IL | Y | $ 19.48 | |
| 11/7/2009 | Injectable Buprenorphin | $ 27.07 | IL | Y | $ 27.07 | |
| 11/7/2009 | Amoxicillin | $ 20.80 | IL | Y | $ 20.80 | |
| 11/7/2009 | Metronidazole | $ 50.70 | IL | Y | $ 50.70 | |
| 11/7/2009 | Tramadol HCL Compounded | $ 34.30 | IL | Y | $ 34.30 | |
| 11/7/2009 | Intest HE K9 14oz Can Qty 10 | Y | $ 25.80 | MI | N | $ 0.00 |
| 11/8/2009 | Day Hospitalization | $ 46.20 | IL | Y | $ 46.20 | |
| 11/8/2009 | Intensive Care Level 1 | $ 15.45 | IL | Y | $ 15.45 | |
| 11/8/2009 | Fluid Therapy Nursing | $ 15.45 | IL | Y | $ 15.45 | |
| 11/8/2009 | Oral/Topical Nursing | $ 9.60 | IL | Y | $ 9.60 | |
| 11/8/2009 | ChlorhexiDerm Flush | $ 19.20 | IL | Y | $ 19.20 | |
| 11/8/2009 | Gentamicin/Clo | $ 26.18 | IL | Y | $ 26.18 | |
| 11/8/2009 | Medical Waste Fee | $ 4.99 | IL | Y | $ 4.99 | |
| 11/10/2009 | Metacam | $ 32.48 | DD | N | $ 0.00 | |
| 11/7/2009 | Tax | $ 2.26 | $ - | |||
| Total | $ 1,858.20 | $ 1,797.66 |
Roxy's policy had a $200 annual deductible, a 20% copay % and a $10,000 annual maximum but no drugs and dental coverage selected for a monthly premium of $32.50. The payout on the claim was calculated as follows (taken directly from the claim Explanation of Benefit)
| STEP 1: Calculate Potential Refund | | | | |||||
| Billed Amount: | | | $ 1,858.20 | |||||
| Covered Charges: | | | $ 1,797.66 | |||||
| Annual deductible remaining | | | $ 200.00 | |||||
| subtotal | | | $ 1,597.66 | |||||
| Copay 20% | (your copayment) | | | $ 319.53 | ||||
| Potential Refund | | | $ 1,278.13 | |||||
| STEP 2: Compare potential refund against your annual maximums | ||||||||
| Annual Maximum | | | $ 10,000.00 | |||||
| Prior refunds for this policy year | | | $ 0.00 | |||||
| Coverage remaining | | | $ 10,000.00 | |||||
| | | |||||||
| Your total refund is: | | | | | | | $ 1,278.13 | |
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