Travel insurance claim denials, particularly ones involving emergency medical services, are rare. But if they happen to you, they can be devastating. Medical costs anywhere in the world are extraordinarily expensive. Don’t take a denial passively. The insurer owes you a clear, detailed explanation. Demand it.
In Canada, all financial service institutions, including travel insurers, are expected to provide access to ombudsman services for aggrieved clients. Some companies are better at it than others. Don’t let them get away with form letters, sloppy research, cursory double-talk or jargon. Get a written, detailed explanation of why your claim was denied, including specifically which clauses in your contract of insurance you are supposed to have contravened, and get a clear explanation of how you can launch an appeal. Make sure you also ask who will implement the appeal.
I know of some travel insurance companies that hand the appeal over to the same people who denied the claim in the first place—that is unacceptable. How can any claims administrator objectively and without bias assess its own work? Also, ask if the appeal will be handled by an officer of the company—someone who, in effect, has a financial interest in the outcome of your appeal. That too is unacceptable.
Travel insurance companies who take the claims appeal process seriously and in good faith with their customers will direct you to an independent professional who knows insurance and has no financial interest in the outcome of your claim. That professional should be paid by the company for his or her work. That is the company’s obligation. Several years ago, some provincial governments (with Ontario in the lead) oversaw ombudsman services for financial service companies, but the companies (banks, insurers, etc.) convinced them they could police themselves, and most committed to providing company ombudsman services. As I said, some have done a better job than others.
In launching an appeal—which does not have to be a long, formal process—demand the clinical evidence upon which the claims assessor based the denial. Where does your family doctor’s medical record show that the condition you had treated while out of the country was pre-existing or was medically unstable? What are the insurers’ definitions of pre-existing and/or unstable? How do they define non-disclosure? Remember that how you or your doctor define such terms is irrelevant. It’s the language in your policy that counts. Those are the rules. You bought into them when you took out the policy. If you didn’t read those terms, that’s your fault.
Demand details: times, dates, medication names and dosages, medical and hospital record notations, and referrals to specialists. Make your claims assessors document their own assertions. Get your questions answered.
Then, if you are still unsatisfied with the insurer’s justification for the denial, or the way the professional ombudsman offered by the company handled your appeal, take your case to the OmbudService for Life and Health Insurance or the General Insurance OmbudService. They will be happy to assess your case, and there’s no charge to you for their services.
A final word: Only after you have gone through these steps should you consider hiring a lawyer. There’s no use in you paying for a lawyer to educate himself or herself about travel insurance at your expense. And no assessment from an ombudsman will prejudice your ability to get a lawyer later if you think you still need one.