Pet insurance claims automation for carriers and MGAs
Pet insurance is the fastest-growing P&C niche - and a soft target for vet-bill upcoding, pre-existing condition concealment, treatment-plan inflation, and pet-identity fraud. Hesper AI runs a full investigation on every flagged pet claim in minutes.
In short
Hesper AI's agents read the vet invoice and clinical notes, match the treatment to the policy's coverage, waiting periods, and exclusions, and check the condition against prior records. Clean pet claims resolve straight through in minutes. Files showing pre-existing-condition concealment or duplicate billing get a full investigation-grade workup instead.
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Common pet insurance fraud schemes
Pet fraud spans individual exaggeration to organized clinic-side billing schemes. Hesper investigates every flagged claim across all four schemes simultaneously.
Vet bill upcoding & duplicate billing
Procedures billed at higher complexity than performed, duplicate line items across claim submissions, and phantom services. Hesper AI maps procedure codes against documented treatment notes and detects altered invoice line items at the pixel level.
Pre-existing condition concealment
Owners enroll pets with known conditions and claim for them as if newly diagnosed. Hesper AI pulls and cross-references prior vet records, OSINT signals, and registry data to surface symptoms or treatments that predate policy effective dates.
Treatment-plan inflation
Treatment durations, medication courses, and rehab protocols inflated beyond accepted veterinary standards. Hesper AI benchmarks prescribed treatment against ACVS, ACVIM, and AAHA guidelines for the breed, age, and condition.
Pet identity & breed misrepresentation
Wrong pet covered under the policy, or breed altered at enrollment to dodge premium loading on breed-specific conditions. Hesper AI verifies microchip IDs across enrollment, claim, and clinic records, and validates breed via DNA registry where available.
Manual workflow vs. Hesper
Every phase compresses. The cumulative effect is the difference between a two-week medical-record chase and a decision in minutes.
How Hesper AI investigates a pet claim
Every pet claim runs through a structured investigation pipeline. Phases run in parallel where dependencies allow.
Vet invoice and medical record ingest
Vet invoices, SOAP notes, lab reports, and imaging are analyzed across 200+ fraud signals. Every document is checked for line-item alteration, font rendering anomalies, and procedure-code mismatches against the documented treatment narrative.
Pre-existing condition forensic check
Prior vet history is pulled across clinics and cross-referenced with enrollment disclosures. The system reconstructs the symptom timeline and flags any treatment, diagnosis, or owner-reported issue that predates the policy effective date.
Treatment necessity vs veterinary norms
Prescribed treatment is benchmarked against breed, age, and condition-specific guidelines from ACVS, ACVIM, and AAHA. Medication courses, anesthesia protocols, and rehab durations are validated against documented standards.
Pet identity and enrollment verification
Microchip IDs, photos, and identifying marks are cross-referenced across the enrollment document, claim submission, and clinic records. Breed claims are checked against DNA registry data where available and against the enrollment photo.
Provider pattern analysis and report
The treating clinic and any referrals are scored against carrier flagged-provider lists and regional billing-pattern norms. A complete investigation report is generated with evidence packages, timeline, and payment recommendation.
North American pet insurance written premium in 2024
7.03 million pets insured
Source: NAPHIA State of the Industry 2025Year-over-year growth in pet insurance written premium
Up from $4.2B in 2023
Source: NAPHIA State of the Industry 2025Hesper AI investigation time per claim
Hesper internal benchmark. Vs. 1-2 weeks manually
Fraud signals per document analyzed
Hesper internal benchmark. Pixel-level plus text-level
Pet claims automation, answered
How does AI claims automation work for pet insurance claims?
The agents read the vet invoice and the clinical notes, map each line item to the policy's coverage, waiting periods, and exclusions, check the condition against the pet's prior records, and produce a decision-ready file. Clean claims resolve straight through. Anything ambiguous or flagged reaches a human with the evidence already assembled.
Can AI detect a pre-existing condition an owner did not disclose?
The agents pull and cross-reference records across clinics, then compare diagnosis and treatment dates against the policy's effective date and waiting period. A condition documented before coverage started surfaces with the record and the date that show it, so a denial rests on a cited document rather than an adjuster's recollection.
How does Hesper handle duplicate or upcoded vet billing?
Invoices run through document forensics for alterations, duplicated line items, and the same invoice submitted twice across policies or carriers. Charges are benchmarked against comparable treatment for the species, breed, age, and region, and providers whose billing keeps running above the benchmark surface as a pattern rather than a one-off.
Can a pet MGA handle rising claim volume without adding adjusters?
That is usually why an MGA looks at this. North American pet insurance written premium rose 20.8% in 2024 per NAPHIA, and the claims are small, repetitive, and document-heavy - exactly the shape straight-through resolution handles well. Your team keeps the exceptions, the escalations, and the denial decisions.
How fast does a pet claim get resolved?
Minutes for a clean claim, and still minutes rather than weeks for one that needs a real investigation, because the investigation phases run in parallel instead of one after another. Manual investigation takes 14+ days per case, which is why most flagged pet claims never get more than a quick look.
Does Hesper replace our claims system or our claims team?
Neither. It integrates with your claims system through the API and writes decisions, evidence, and recommended actions back to the file. Adjusters keep decision authority on coverage, payment, and denial. The agents do the reading, matching, verifying, and citing that currently eats the day.
Go deeper on pet claims fraud
Research, technical deep-dives, and playbooks from the Hesper AI team.
See Hesper investigate your pet claims
We'll run a sample investigation on your real flagged claims and show you the evidence package and report it produces.