Though travel insurance claim denials are rare events, they are sure to capture headlines when they do happen. In fact, according to a recent survey conducted for the Travel Health Insurance Association of Canada (THIA), 95 percent of all travel claims submitted in Canada are paid.
But the consequences of even one claim denial can be frightening and financially devastating. Nobody benefits by a claim denial: obviously not the client, and certainly not the insurer who must absorb the bad publicity and ill feelings such a negative event causes.
If It Happens to You
Any claim denial should explain in clear, plain language the specific exclusion being applied. For example, if the exclusion precludes payment for an unstable pre-existing condition, you should be shown the evidence in your doctor’s medical records that a condition truly was pre-existing, or unstable, or warranted reporting on a medical underwriting questionnaire. The citation should be specific.
You deserve to see all the details and records you need so you might appeal the decision to an established group or appeals committee —perhaps with the help of your physician, who can explain your medical history and the reasons for his or her treatment interventions.
Also, take the time to write to the appeals committee. Explain your version of events, but stick to facts that can be documented by your physician’s medical records, consultations, prescription or pharmacy records, dates of tests and other medical interventions. Don’t let emotional appeals get in the way of the documented facts supporting your case.
If Your Appeal Fails
Ask to have your case further reviewed by your insurer’s designated dispute-resolution or ombudsman services. These are independent resources free to you, who will review all of the documentation that is relevant to your case and give you an opportunity to state any further views or records you think may clarify or support your position.
Whether the review goes your way or not, it should be detailed, and it should give clear reasons for the recommendation rendered. There should be no doubt in your mind why the reviewer made the recommendation he or she made.
That decision will, however, be only a recommendation, and neither you nor the insurer will be bound by it, although it may certainly add weight to the denial or its reversal. You can always seek legal advice later on.
As part of that report, the OmbudService may direct you to additional provincial or national resources that are specifically designed to hear consumer complaints and concerns, including those relating to travel insurance: OmbudService for Life and Health Insurance or the Canadian Life and Health Insurance Association.
OmbudServices are an Extra Layer of Consumer Protection
OmbudServices have a good deal of latitude in assessing appeals and eliciting information from travel insurance customers as they are designed to look at any given situation from all sides, objectively and fairly. But they must still be guided by the terms of the policies purchased and the limitations and exclusions that govern them. After all, these are contracts between the consumer and the insurer.
The consumer may say there is too much fine print.
On the other hand, the insurer has a sound argument in stating that unjustly paying out a claim penalizes other travelers who ultimately end up covering those costs in increased premiums.
Consequently, you are still responsible to know the terms of your contract, understand its limits, and share the responsibilities you signed on for when you make your purchase.
Don’t Let US Hospitals Bills Rock You
For many Canadians, who never see hospitals bills while at home, the statements they may see from US hospitals (if they don’t have travel insurance protecting them) can be heart-stopping. Six-figure bills for a four-day stay are not extraordinary.
If you should receive such a bill, your first reaction might be to seek instant legal help. I would never advise you not to see a lawyer, but take a deep breath and look at other, more immediate options first.
If your insurer has not yet dealt with the case (there is a lot of paperwork to gather before cases can be concluded) stay in touch and be guided by their advice. Don’t start negotiating with a hospital while your insurer is still on the case.
If the claim is denied and you end up with the responsibility for payment, ask your insurer to help you negotiate a settlement with the hospital and/or doctors seeking reimbursement. They can often get substantial reductions.
If you want to handle the matter on your own, understand that US hospitals rarely get their full charges. Insurers don’t pay retail, and some states have mandated that hospitals charge uninsured patients no more than they would charge insurers. It is not unusual for major insurers to pay perhaps 25 to 30 cents on the dollar charged. That may be a good place for you to start in any negotiation. You need not fear coming in too low. You may be surprised what a hospital administrator may accept lieu of suing you in a foreign country.
The fact is you probably just had your health restored to you, and that is worth something. Remember: you are not defenseless.
Do you have pre-existing conditions and wish to take a trip? Speak to a travel medical insurance agent today.