my dog was approved for surgery at primary vet. when vet saw the extent of the injury,thankfully he said he was not qualified to do the surgery and sent us directly to trauma vet. trupanion did not want to pay because they had not approved for this vet to do surgery. thank God we didn't answer cell phone as we were driving and kept on to trauma vets office. we waited 41/2 hrs, with tru panion and the vets office telling them how badly she needed the surgery. they kept refusing, but after 4 hrs they relented and ok'd the surgery. we were all at our wits end by then. I am torn as to whether I would recommend them to anyone because of this. but they did ok surgery and gave me the amount I would be paying right away, so that was a positive in their favor.