standards of veterinary medicine

Citation: Becker, M.; Volk, H.;
Kunzmann, P. Is Pet Health Insurance
Able to Improve Veterinary Care?
Why Pet Health Insurance for Dogs
and Cats Has Limits: An Ethical
Consideration on Pet Health
Insurance.
Animals 2022, 12, 1728.
https://doi.org/10.3390/
ani12131728
Academic Editor: Alexandra
Whittaker
Received: 15 May 2022
Accepted: 1 July 2022
Published: 4 July 2022
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animals
Article
Is Pet Health Insurance Able to Improve Veterinary Care? Why
Pet Health Insurance for Dogs and Cats Has Limits: An Ethical
Consideration on Pet Health Insurance
Michelle Becker 1,*, Holger Volk 2 and Peter Kunzmann 1
1 Stiftung Tierärztliche Hochschule Hannover Institut für Tierhygiene, Tierschutz und Nutztierethologie (ITTN),
Bischofsholer Damm 15, Gebäude 116, 30173 Hannover, Germany; [email protected]
2 Stiftung Tierärztliche Hochschule Hannover Klinik für Kleintiere, Bünteweg 9, Gebäude 280,
30559 Hannover, Germany; [email protected]
* Correspondence: [email protected]
Simple Summary: The standards of veterinary medicine are increasingly approaching those of
human medicine. As a result, the cost of veterinary medicine is also rising noticeably. For many
veterinarians and also pet owners, the question therefore arises as to whether animal health insurance
is a possible solution. Based on a thought model, we have classified pet owners into four groups
according to their willingness to pay and their dispensable funds. We found that animal health
insurance can reduce price discussions, but reaches its limits as soon as an animal owner can afford
neither the veterinary costs nor a monthly insurance premium.
Abstract: Background: Owners often feel the cost of veterinary care is too high, as there remains a
limited understanding of the cost of health care in human and veterinary medicine alike. Pet health
insurance is often seen as a universal solution. However, especially for patient owners with few
financial resources, both the bill at the vet and the monthly premium for pet health insurance can
become a challenge. Hypothesis: Pet health insurance can prevent or ease many price discussions
at the vet, but it does not offer a solution for patient owners with little financial means. Methods:
In order to verify for which patient owners pet health insurance can be a solution, four theoretical
groups were formed depending on the patient owner’s willingness to pay and his/her dispensable
funds based on a theoretical model. Results: Dispensable funds are a factor that cannot be influenced
by the veterinary surgeon. However, low dispensable funds as a result of an insufficient willingness
to save (whether due to a lack of financial education or a lack of will) can be solved by pet health
insurance. Willingness to pay, on the other hand, can be influenced by empathetic communication
from the veterinary surgeon and thus also from pet health insurance. Nevertheless, situations remain
where pet health insurance is not a solution either, because owners can neither afford the veterinary
costs nor a premium for a pet health insurance.
Keywords: pet health insurance; animal ethics; animal welfare; price discussions
1. Introduction
Financial discussions occur daily in small animal practice [1], which can be frustrating
for the whole veterinary team, but for the veterinary surgeons in particular. Owners often
feel the cost of veterinary care is too high, as there remains a limited understanding of the
cost of health care in human and veterinary medicine alike.
Dealing with financially limited clients can quickly become a burden for veterinary
surgeons and increase the stress level at work [
2,3]. This is in part due to veterinary
surgeons wanting to provide the best possible care for each individual animal, which
clashes with owners’ financial constraints and the misconception of some owners that
veterinary surgeons are mainly motivated by making a profit.
Animals 2022, 12, 1728. https://doi.org/10.3390/ani12131728 https://www.mdpi.com/journal/animals
Animals 2022, 12, 1728 2 of 10
Kondrup’s results show that ethical issues arise, affecting veterinarians personally and
guiding the selection of treatment options [
1]. The veterinary profession has advocated for
strengthening the pet health insurance market to improve pet health care for the benefit of
all stakeholders [
2,4].
Can pet health insurance really solve most of the challenges of small animal practice
mentioned above? The stakeholders in a veterinary appointment are the animal, the
owner and the vet. What are their needs, and is pet health insurance able to better fulfill
those needs?
Veterinarians and owners have a common interest in the welfare of the animal.
According to the RCVS code of professional conduct [
4,5], it is part of the veterinary
profession to “ensure the health and welfare of animals”. This is also part of the declaration
every veterinary surgeon makes. The owner can also be said to have a fundamental interest
in the welfare of his animal, since in many cases the relationship with his animal can be
described as similar to that of his own child. [
6]
Clients’ expectations were also identified by Kirsty Hughes et al. [
7]. They designed a
“Veterinary client hierarchy of needs”, which defines clients’ needs as follows:
The animal’s welfare;
Clinical problem-solving ability;
Professionalism;
Communication skills;
Working in partnership.
“Some capabilities are considered essential while others are considered as valuable add-ons once the fundamentals are in place. It may be that our clients coming
to see the vet that their first priority for their animal is its safety and physiological
needs and that once they see those being met, they can then prioritize their own
psychological needs”.
In addition, both in the UK and in Germany, pet owners are legally obliged to care for
their pets.
The UK legislation defines the duties of a “person responsible for an animal to ensure
welfare” as follows [
8]:
“(2) For the purposes of this Act, an animal’s needs shall be taken to include—

(a) its need for a suitable environment,
(b) its need for a suitable diet,
(c) its need to be able to exhibit normal behaviour patterns,
(d) any need it has to be housed with, or apart from, other animals, and
(e) its need to be protected from pain, suffering, injury and disease”

German legislation sees the protection of animals as a human responsibility and holds
that “pain, suffering or harm” [
9] to animals can only be applied with a legitimate and
justified reason. Thus, from a legislative perspective, pet owners should be able to care
for their pet adequately in health and disease. Legislation provides a basis for deciding
how costs can be paid in an emergency before the emergency occurs. Otherwise, dilemmas
can arise for all parties involved, which can put a heavy burden on the parties involved
(animal, owner, veterinarian).
As mentioned in UK legislation, German legislation defines the responsibilities of pet
ownership as follows: Your duties are to offer a diet, care and accommodation according
to the needs of the pet. You may not restrict species-appropriate movement if this causes
unnecessary suffering and pain. You have to acquire appropriate knowledge about the
points mentioned above [
9].
The animal’s expectations can be defined as the fulfilment of basic needs, such as
the Five Freedoms, but also the quality and quantity of life should be maximized. The
Five Freedoms are defined as freedom from hunger and thirst; freedom from discomfort;
freedom from pain, injury and disease; freedom to behave normally; and freedom from fear

Animals 2022, 12, 1728 3 of 10
and distress [10]. The freedom from pain, injury and disease can especially be addressed
by pet health insurance.
Veterinary surgeons often find themselves in a difficult situation, on the one hand
wanting to care for the animal, and on the other hand considering the owner’s financial
capabilities and value system. It is a conflict between the original decision of becoming a
vet, with fulfillment of the animal’s needs as the highest value, and letting owners decide
which diagnostic and therapy they want to choose. “For in any veterinary consultation
in any branch of the profession, there are three interested parties: the client, the animal
and the practitioner him- or herself” [
11]. One possible solution for this conflict may be
understanding the patients’ needs. These are as described by Coe [
12] as follows:
Care of the animal should take precedence over monetary aspects.
[ . . . ] There was an expectation among some participants that out of a shared
interest for the pet, the veterinarian would work with the client to find a solution
if the client could not immediately afford veterinary care. [ . . . ]
Discussions of costs should be initiated upfront.
Costs of veterinary care should be placed in a meaningful context.
[ . . . ] Costs should be discussed within the context of their pet’s health and
prognosis, stating, for instance, that “I want the information about cost in the
context of what’s a reasonable prognosis.”
Client suspicion should be addressed.
[ . . . ] The most consistent suspicion arose from the conflict between the idea of
veterinary medicine as a health-care profession versus a business.”
Meeting the needs of clients is important to satisfy both veterinary surgeons and
clients in daily veterinary practice. It may also make a huge difference for a better working
environment with less daily conflicts.
Johanna Kersebohm [
4,13] has identified vets’ expectations of their workplace and
working environment. The two most important ones are a good working atmosphere and
an appropriate salary. These two factors are largely determined by how the vet experiences
their time in consult: most of the time is spent in consults every day, which are also the
main contributors to the revenue of a practice. During this time, discussions about cost and
ethical dilemmas can arise [
14].
Insurers, as one of the stakeholders of pet health insurance, see an interesting niche
market in Germany that they would like to tap into. They are aware of the problem of
unpaid veterinary bills and would like to establish veterinarians as multipliers in order to
create a win-win situation [
15].
Despite pet health insurance being a solution to improve pet health care, many owners
choose not to take out a policy for their pet due to financial constraints or restricted coverage.
The current study investigates if a voluntary pet insurance system could resolve these
conflicts and provide accessible care for pets. Would this have a direct effect on animal
welfare (“According to studies, dog owners with pet health insurance spend 29 per cent
more annually for veterinary care; cat owners 81 per cent more.” [
16]) or only an indirect
one by enabling the vet to have discussions with the owners which are not financially
restricted and to see cases on regular routine health check-ups?
As mentioned above, veterinary surgeons have a fundamental interest in the wellbeing
of their patients. However, in contrast to the patients’ owners, there is one additional point:
to be able to work in the profession in a financially sustainable and healthy way (physically
and mentally).
The aim of this work is to find out if pet health insurance is really as helpful as is
claimed in veterinary press.
“Since the 2005 change in the law preventing veterinary surgeons from recommending particular insurance products, we have lost a very useful symbiotic
relationship with the insurance industry” (GB) [
17].
Animals 2022, 12, 1728 4 of 10
“[ . . . ] [Owners] will no longer have to worry whether or not they can afford the
necessary veterinary attention. If an animal is insured by a caring owner for this
laudable reason, it frees us to consider only the animal’s health and welfare and
ensure we reach an accurate diagnosis and satisfactory conclusion [ . . . ]” (GB) [
4].
2. Methods
To find out how to solve price discussions, it is worth taking a look at their origin. This
work is based on a theoretical model.
Due to the fact that surveys often distort the picture of reality, we have deliberately
chosen a thought model. This effect has already been demonstrated in the area of price
sensitivity for fresh meat. In surveys, the majority of consumers stated that they would
accept a price premium of just over 30% if more animal welfare could be guaranteed [
18].
In a supermarket study, however, this willingness to buy was disproved [
19]:
“The results are surprising, as various surveys have shown that many consumers
are willing to spend significantly more money on meat if it has been produced
according to higher animal welfare standards. The results of the present suggest
that the observed reality of actual purchasing behavior is more differentiated
and complex. The basic willingness to spend more money on such meat in the
test for such meat is only pronounced to a limited extent. General statements on
willingness to buy should therefore be viewed critically.”
Although the consumption of meat is a voluntary purchase, while consulting a veterinarian in the event of illness is not a voluntary decision, the parallel is intended to illustrate
how large the gap often is between a statement made and actual action in society.
Therefore, the added value of this theoretical model is that, supported by the existing
literature and a theoretical analysis of the current situation, potentials and limitations of
animal health insurance can be shown.
The basic idea of the following thought model is that price discussions often arise for
two reasons: either the owner does not have the financial means to pay, or he does not
want to use the required resources.
Thus, financial conflicts can be reduced to two fundamental factors: willingness to
pay and dispensable funds.
These two factors combined lead us to four different situations. Thus, we have
developed a model which helps to classify patient owners in terms of their willingness to
pay in relation to their financial capacity. Based on this model, predictions of pet health
insurance limitations and capabilities can be drawn.
The two factors “willingness to pay” and “dispensable funds” of patient owners can
be combined into four different categories:
1. High willingness to pay (WP) and high dispensable funds (DF);
2. High WP and low DF;
3. Low WP and high DF;
4. Low WP and low DF.
WP depends on the human–animal bond. When the relationship of the owner with
the animal is very close, the owner is more willing to spend money on her or his pet.
(According to the NAPHIA Press Kit, pet owners spend more at the vet when they have
pet health insurance in place. Reasons for purchasing PHI include that it “is helpful to
pet owners,” “shows you love your pet” or “helps avoid the need to make painful choices
about care.” In other words, many reasons for taking out pet health insurance indicate a
close relationship with the pet and are intended to open the door to expensive diagnostic
and treatment methods [
16].) In the media you often find only positive statements about
the relationship, especially between man and dog [
20,21], but this relationship can be very
complex [
22]. Owners rarely would admit that they have a more practical, less caring
relationship with their pet.

Animals 2022, 12, 1728 5 of 10
3. Results
Four groups of patient owners could be identified in the model above.
Group 1: high WP/high DF
This owner loves his pet and is willing to pay all the bills that come with it. This group
is found in many households that acquire a dog or cat which lives with them inside the
house. Health insurance for the pet is self-evident, as the vet has recommended it and the
owners want only the best for their pet.
Group 2: high WP/low DF
This owner also loves his animal, but has limited dispensable funds available. Often
the animal is an emotional support or at the time of purchase the awareness of possible
costs and the responsibility to care for the animal was low. This group is often found in
socially weak households. In this case, if the owner is aware of possible veterinary costs,
PHI is a good way to cushion financial peaks and convert them into monthly amounts.
Groups 3 and 4: low WP/high DF and low WP/high DF
This owner has a low emotional attachment to his pet. This may be the case if the
animal has a specific task. In the case of dogs, for example, this can be the herding of sheep
or personal protection. In the case of cats, this could be keeping away pests such as mice or
rats. As part of the pet owner’s responsibility for the animal, a monthly payment might
actually be more convenient for these owners than individual vet bills, as it makes costs
more predictable.
A low willingness to pay can also occur if not all family members agreed with the
acquisition of the animal.
Groups 3 and 4 differ only in the (non-)presence of financial means.
4. Conclusions
As shown in Figure 1, pet health insurance is not needed for the high WP/high DF
group, but is a solution for owners who have been categorized either in high WP/low DF,
low WP/high DF or low WP/low DF. However, for the high WP/low DF or low WP/low
DF group the question remains if pet ownership is in general justified.
In the high WP/low DF group, owners would be willing to pay but their means are
restricted, leading to the high frustration of owners and vets alike. The low DF is due to
the fact that the income or assets are generally too low to pay for veterinary bills.
In Germany, anyone who “keeps, cares for or has to care for an animal” is legally
responsible for “feeding, caring for and housing the animal in a manner appropriate to
its species and needs” and for acquiring the relevant knowledge. This includes nutrition,
care (also in case of illness) and accommodation, but also the necessary “knowledge and
skills” [
9]. In the Animal Welfare Act, it is equally written that owners must protect their
animal from pain and suffering [
8]. It is therefore questionable in this case whether keeping
animals is ethically justifiable.
Another scenario for a low DF is a low willingness to save money. Most owners are
aware of the annual costs for a general health check, vaccinations, flea/tick treatment and
deworming when they purchase a pet. However, there is a limited understanding of costs
which arise due to an illness. Most people have neither the foresight nor knowledge of how
high veterinary costs can be. If that were the case, there would be no price discussions and
fewer people would keep an animal unless they consciously accept the risk of a veterinary
shortage. They might also not have the discipline to set aside a fixed monthly amount.
Even if an owner does save money health costs for their pet, it might exhaust their savings
quickly. It is therefore obvious to consider animal health insurance as a possible solution.

Animals 2022, 12, 1728 6 of 10
Figure 1. Patient owners’ willingness to pay depending on dispensable funds.
The relationship of the low WP/high DF group to the animal is rather pragmatic. It is
possible to keep the animal for a certain benefit, for example, a cat to keep the mice at bay
or a guard dog for personal or property protection. Veterinary expenses are limited in this
case to keeping the animal healthy, always with a cost–benefit calculation being carried
out, which of course quickly reaches its limits when higher expenses are incurred. It is
important to inform the owner that keeping an animal is also associated with the obligation
to care for it in a species-appropriate manner. This naturally includes adequate veterinary
care. Paragraph 1 of the Animal Welfare Act provides the basis here: “The purpose of
this Act is to protect the life and well-being of the animal as a fellow creature out of the
responsibility of man for the animal. No one may inflict pain, suffering or harm on an
animal without reasonable cause” [
9]. As mentioned above, the UK’s Animal Welfare Act
demands freedom from “injury and disease” [
8].
Predictable costs are easier to accept than one-off, large sums of money that are covered
in an unscheduled manner and appear to be lower overall than the full amount of costs.
This is the reason why instalment payments are very popular with consumers [
23]. Pet
health insurance, together with legal and ethical argumentation, can therefore certainly
represent a solution here as well.
Group four has both a low WP and a low DF, so if there are no available funds because
the money has been spent on something else, pet health insurance could be a solution in
that the patient owner can be convinced of the relevance of the product and monthly costs
are better accepted than isolated monetary spikes.
If there are no available funds due to low income and a lack of reserves, the question
arises as to why the owner owns this animal. If the farm is supported by dogs and cats
(herding dogs, guard dogs), then in the absence of financial resources, the starting point is
not likely to be PHI.
In summary, the following possible scenarios can be identified here which could
potentially be solved by pet health insurance.
An insufficient willingness to save (whether due to a lack of financial education or
a lack of will) can be solved by pet health insurance. The monthly contribution is then
deducted from the account without the owner’s intervention. A low WP in combination
with a low DF could also be solved by pet health insurance. In all situations the decision
for or against pet health insurance or the importance to inform about it remains the same.
The fact that the veterinarian plays a major role in the advice given has been demonstrated,
at least in North America: “The survey among pet owners demonstrated that 50 per cent

Animals 2022, 12, 1728 7 of 10
more pet owners would likely purchase pet health insurance if their veterinarians actively
recommended it” [
16].
Pet health insurance could bring added value to animal welfare in the mentioned
situations. Animal welfare can be improved if the choice of the optimum diagnostic and
therapeutic method can always be made on the basis of ethical considerations rather
than financial limitations, and if an animal is regularly presented for a preventive health
check-up [
24]. Some pet owners do not bring their pet for a regular health check-up due
to financial concerns: “In a study of pet owner expenditure, Henderson [ . . . ] found
that financial issues were a barrier for pet owners when it came to preventive, sick, and
emergency care” [
25]. However, early detection of diseases can be essential and significantly
improve the quality of life.
Still, situations remain where pet health insurance is not a solution either, because
owners can neither afford the veterinary costs nor a premium for pet health insurance.
As described in depth here, pet insurance could help to cover the costs of veterinary
care. However, the actual costs might not be the biggest challenge for the veterinary
profession. According to Brennecke and Münow, the reason for a lack of acceptance of
prices is not to be found in the price itself but in the way a patient owner feels treated.
Guido Bentlage writes about this: “Above all, owners want to be treated friendly. They
want a committed, caring veterinarian who takes time for them and their animal. [ . . . ]
Contrary to what most veterinarians actually expected, the price, i.e., the costs, was even at
the bottom of the ranking. As already mentioned, friendliness was by far in first place” [
26].
“The focus or, rather, the entire objective of veterinary activity should be on
customer satisfaction, in which medical quality, although a very important part,
is just one part.”
“Pet owners’ expectations according to ranking (Brennecke 2009)” [
26]:
Friendliness;
Attention;
Helpfulness;
Telephone/personal availability;
Speed;
Reliability;
Professional/social competence.
As we have seen in the results of Kirsty Hughes, it is important to first build a base: the
animal’s welfare plays a fundamental role. Only if this need of the owner is fulfilled is there
the opportunity to win over the owners with friendliness and empathic communication
and to profit from the interaction due to professional competence and customer-orientated
service.
Information about the costs involved is also part of good advice and even contributes
to customer satisfaction [
26]. Empathic communication and active listening can reduce a
large part of both price discussions and the resulting ethical dilemmas, as well as having a
positive effect on the economic profit of a veterinary practice [
27].
Vets often focus too little on costs and see costs as a limitation to better pet health
care. Pet health insurance seem to be an easy solution to address discussions around costs.
However, as aforementioned, owner needs are not cost-related, but perceived value-related,
and can be addressed with professionalism and verbal and non-verbal communication
with empathy, helping to build a trustful relationship between the veterinarian and patient
owner [
28]. Therefore, the pet health insurance debate might be over-inflated and play a
smaller role than anticipated. Moreover, unless pet health insurance would be obligatory,
mainly owners with appropriate financial means will spend their disposable funds for
health insurance, and they are most likely also able to afford care without insurance.
The situations that really pose a challenge are those where the patient owner really
has no money for treatment. As filtered out in the model, some of these patient owners
can make the money available through predictable payments for pet health insurance, but

Animals 2022, 12, 1728 8 of 10
those who cannot do so cannot afford either treatment or pet health insurance and are thus
excluded from the scope of pet health insurance. The ethical question, however, remains if
these individuals should have a pet if their funds are so limited. Dispensable funds are a
factor that cannot be influenced by the veterinary surgeon.
Willingness to pay, on the other hand, may be influenced by empathetic communication from the veterinary surgeon. Communication needs to be improved not only
in the consult room, but also to the public, so there would be a better appreciation and
understanding of the cost of pet health care.
Further Perspectives and Conclusions for Practice
As described in the article, PHI can be a positive contribution in the field of small
animal medicine and serve as a valuable support in the treatment situation of small animal
medicine. However, in Germany, so far significantly fewer dogs and cats are insured than
is the case, e.g., in UK.
So how can the product be made more attractive so that more pet owners take advantage of it?
Looking at the general functioning of an insurance company, it is a characteristic of the
system that with a larger pool of insured persons, the monthly premiums decrease due to a
risk equalization: “The [risk equalization] in the collective finds expression in the fact that,
under otherwise constant conditions, a growing collective size offers advantages. These
advantages consist in the fact that, as the size of the collective grows, either the random risk
itself is reduced or, with a constant (controlled) level of security, the insured total loss can
be financed more favorably on average, making it cheaper for the individual policyholder
to purchase insurance coverage” [
29].
This means if the product were more attractive (both in terms of price and content),
more people would likely take advantage of it. However, this only works with an increased
pool of insured dogs and cats.
Would mandatory health insurance for animals be a possible solution at this point?
Fundamental challenges are already encountered in the design of the content [
30].
Considering the models of health insurance from human medicine as a basis, a mixed model
of Bismarck and Beveridge would be conceivable. PHI would therefore be subsidized from
government funds. This state of affairs can be questioned as quite unrealistic, at least in
the near future for our pets. Thus, excluding this subsidy, we are left with a pure Bismarck
model, i.e., payment of health care costs from premiums without government subsidy.
While this fact in itself sounds superficially feasible, it does not solve the fundamental
challenges mentioned at the outset, which essentially relate to the design of exclusions and
the assessment of premiums.
How can the findings now be profitably used in practice?
As the NAPHIA Press Kit recommends [
16], the veterinary practice is the number
one source of information for animal health insurance. With education about potential
veterinary costs and recommendation to inquire about PHI, more pet owners will be made
aware of the benefits of pet health insurance.
Author Contributions: M.B., conception, first draft and elaboration; P.K., support with conception;
H.V., linguistic revision. All authors have read and agreed to the published version of the manuscript.
Funding: This Open Access publication was funded by the Deutsche Forschungsgemeinschaft (DFG,
German Research Foundation)—491094227 “Open Access Publication Costs” and the University of
Veterinary Medicine Hannover, Foundation.
Institutional Review Board Statement: This work does not include animal studies.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors have no conflict of interest to declare.
Animals 2022, 12, 1728 9 of 10
Abbreviations

DF Dispensable funds
NAPHIA North American Pet Health Insurance Association
PHI Pet health insurance
RCVS Royal College of Veterinary Surgeons
UK United Kingdom
WP Willingness to pay

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