4 Reasons Your Insurance Claim Might Be Denied

When you buy travel insurance, the hope is that you are purchasing some peace of mind for your trip. However, every once in a while, a high-profile case hits the news about a claim that was denied, leaving the claimants with huge medical bills. This understandably has some travellers concerned about how much they can actually rely on their insurance policy.

The good news is: as long as you fully understand the workings of your insurance policy, there’s no need to fear an unexpected surprise from your insurer. To help you gain that confidence, let us explain the four main reasons why someone’s insurance claim might be denied.


Why could my claim be denied? 

1. Because your claim was related to a pre-existing condition.
This is a term one hears often when it comes to travel medical insurance, and there can be some confusion around what it really means. Put simply, a “pre-existing condition” is a medical condition that you were already suffering from at the time you applied for your insurance. Many travel insurance policies will not offer compensation for any claims related to a pre-existing condition.That said, these days there are some specialized plans on the market that will cover pre-existing conditions under certain circumstances. If you’re in need of this kind of coverage, it’s a good idea to talk to your insurance broker about your options—your insurance coverage will only work for you if you choose a plan that suits your needs.


2. Because your medical status changed before you travelled.
When you apply for travel medical insurance, your application is based on your health status as described on your application. Should there be a change in your health before the date when your travel (and coverage) commences, you are obligated to report the change to the insurer. Otherwise, your claim can be rejected on the grounds that your application was inaccurate.
What many travellers don’t realize is that this applies to minor changes as well as major ones. For instance, a change in prescription medication must be reported—even if it’s just your doctor switching you from one brand of a drug to another. The same goes for the diagnosis of a minor condition that your doctor told you not to worry about.As far as plans covering pre-existing conditions, many include what is called a “stability clause.” This means that your pre-existing condition will be covered only if you haven’t experienced any changes in the condition for a specified period of time. And “changes” even includes improvements—lowering the dosage of your medication, for instance, could still qualify a condition as “unstable.”The bottom line: it’s always best to share any new information with your insurer to make certain all your bases are covered.


3. Because there was information missing from your insurance application.For example, if you had a pre-existing condition that you neglected to inform the insurer about. Even if said condition had absolutely nothing to do with your insurance claim, the lack of disclosure is still acceptable grounds for your claim to be invalidated.For this reason, it’s critical that you be honest, accurate, and thorough on every medical insurance application that you fill out—and it’s a good idea to speak to your doctor for the full details. In some cases, a doctor will make a note in a patient’s medical history and not share that information with the patient (perhaps because they consider it unimportant to do so). Unfortunately, this kind of withheld information can still invalidate an insurance claim, even when you didn’t know about it yourself. If you’re uncertain, ask your doctor for a copy of your medical records.


4. Because you made a claim for something that was excluded under your policy.
There is no standard set of benefits that comes with an insurance policy; every policy is different. That’s why it’s so important to do your research (or speak with qualified experts) when choosing your policy.Importantly, each policy will have a list of “exclusions,” or things that it will not cover. For instance, many travel insurance policies exclude injuries resulting from extreme sports. If you’re hoping to go skydiving on your vacation, in other words, you will need to seek out a specific policy that addresses your needs.More generally, every policy has different levels of coverage and different benefits, which is why it’s so important to read the fine print. What’s the maximum your policy will pay out in case of an accident? Does your policy include dental work in its list of benefits? How about trip cancellation insurance? If you’re confused, consult an expert who can go through the policy with you and make sure you understand exactly what you’re being covered for.


So, what can I do to make sure my claim isn’t denied?

In brief, these three simple steps are your best defence against a denied claim:

  • Always read your policy from start to finish, including the fine print.
  • Complete all medical applications carefully, completely, and accurately.
  • Get help from an expert to make sure you fully understand your coverage.

I believe my claim was unfairly denied. Do I have any options?

There is still recourse even if you claim has already been denied. If you believe your situation should have been covered under your policy, and if you have evidence to back this up, you should contact your insurer in writing and present the evidence to them. If that doesn’t work, try contacting the OmbudService for Life and Health Insurance for help with your case.

It is worth noting, however: although denied claims are the ones that grab attention and make headlines, this is not the norm in the travel insurance industry. The vast majority of insurance claims are, in fact, paid.

With all of this knowledge on your side—and by paying careful attention to your policy details—you should be well-prepared in the event of a future insurance claim.


Do you still have questions? We can help! Contact us today.

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