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How to prevent the denial of your claim

Category : Advice from our experts  
Étiquettes :

Don’t be Mr. and Mrs. Sorry – Be Mr. and Mrs. Right!

We sometimes hear that insurers will do anything in their power to deny a claim. There is nothing farther from the truth, at least for Tour+Med / LS-Travel! We pride ourselves in having one of the lowest claim denial ratios in the industry. Despite this, you have to be aware of some of the most important provisions about your coverage before leaving on your trip. Simply put, following the general rules outlined below will minimize any problems that may arise at claim time.

The cover letter that accompanies your application contains very important instructions, such as:

There is an actual financial exposure when you travel. Continue reading to find out about cases recently experienced by real clients. Although we pay the vast majority of claims, we present you with situations where claims were either paid or denied, to outline the importance of following the 4 simple rules presented above, and in the letter that accompanies your Travel Insurance Confirmation.

(Certain details have been modified to keep the identity of the concerned clients anonymous, but amounts and situations are real.)

Rule #1: Review your Travel Insurance Confirmation and medical declaration, if applicable

Your medical declaration is the basis of your contract with us. Your Travel Insurance Confirmation also presents essential information, such as your travelling dates, your age, etc. Take the time to review your documents upon receipt. Make sure that you answered each question truthfully and accurately. Be mindful of the consequences an omission or false declaration might have on a claim. If you are unsure of your medical conditions, you must speak with your doctor.

If your insurance was purchased a while before your departure date, review your confirmation again in the days that precede your departure. Ensure that your answers have not changed and that you still meet the eligibility conditions. Any changes to your health must be reported to the Insurer; otherwise, your coverage might be invalid if your declaration does not reflect your medical history accurately.

Did your spouse answer the medical questionnaire for you? Take the time to review the questions and answers carefully, and report any mistake to your broker or to the insurer before your departure. Reviewing your medical declaration will only take a few minutes and will eliminate many complications in the event of a claim.

Advice from our experts: Making a false declaration or omission on your medical declaration could reduce your premium by a few dollars, but will never be worth it when facing a high dollar claim! Make sure you understand each question so you can answer truthfully and accurately.

See the real cases of Mr. Sorry and Mr. Right

M. SORRY

Total claim costs: $126,000 USD

Mr. Sorry was enjoying a day on the golf course when he started feeling sick. He ended up in the hospital with a rare affection that left him intubated and paralyzed within 48 hours of his admission. Once stabilized, he had to be air evacuated back to his home province for his long recovery. A 3-day stay in the hospital cost $108,000 USD and his repatriation via air ambulance was worth $18,000 USD.

At the time of purchase, his spouse had answered the medical questionnaire for him. Not wanting to worry his wife, he had kept important medical information from her and she did not know about his whole medical history. Rather than providing the appropriate information to the insurer, Mr. Sorry chose to remain silent, knowing too well that his medical declaration was incomplete. He thought everything would be fine and that “it only happens to others”.

The insurer denied this claim because, not only was Mr. Sorry’s declaration inaccurate, but he also was not eligible as per the insurer’s eligibility conditions. The premium was reimbursed and the policy was rendered null and void.

Who knows if Mr. Sorry would have left on his trip, having known this!

Mr. RIGHT

Total claim costs: More than $800,000 USD

While in Arizona, Mr. Right had to be admitted to hospital due to a cerebrovascular accident (CVA). The situation was, of course, very serious. He was intubated and non-responsive for a while. His wife spent days at his bedside despite the dark prognosis of any recovery. Three weeks later, still hospitalized, he was stable enough for an air ambulance transfer back to his home province, where he miraculously recovered with minimal sequelae. The hospital bill alone was over $600,000 USD.

Thankfully, Mr. Right had disclosed his complete medical history to his broker. His declaration being complete and accurate, the claim was paid in full. He was very happy and relieved to be able to concentrate on his recovery and not have to worry about paying well over $800,000 USD worth of medical expenses!

Unbelievably, he was able to travel again the year after and we were happy to cover him once again.

Rule #2: Let the insurer know of any change in your health prior to the effective date of your coverage

Pre-existing conditions, whether declared or undeclared, are subject to stability requirements. Many things can alter a condition’s stability. You must also note that an insurer’s definition of stability differs from your physician’s definition. You must read and understand our definition of “Stable and Controlled”:

Stable and Controlled” Means any Medical Condition (other than a Minor Ailment) for which all of the following statements are true:

  1. There has not been a new diagnosis, any new Treatment prescribed or recommended, or Change(s) to existing Treatment (including a stoppage in Treatment), and
  2. There has not been any Change to any existing prescribed Medication (including an increase, decrease, or stoppage to prescribed dosage), or any recommendation or starting of a new prescription Medication (exceptions: the routine adjustment of Coumadin, Warfarin or insulin and the change from a brand name Medication to a generic brand Medication of the same dosage); and
  3. There has not been any new, more frequent or more severe Symptoms, and
  4. There has not been any Hospitalization or referral to a specialist, and
  5. There has not been any medical exam, investigative testing or test results showing deterioration; and
  6. There has not been any Treatment recommended, planned or not yet completed, nor any outstanding test results.

All of the above conditions must be met for a Medical Condition to be considered Stable and Controlled.

(The meanings of words in italics are explained in the “Definitions” section of the insurance policy. In case of disparity between the definition above and the definition in the policy, the latter prevails.)

Ask questions and know the impact a change in stability could have on your coverage. If a condition does not meet our stability requirement, inquire about our Reduced Stability Period option. We may be able to cover your condition.

It is very important to review your medical declaration and insurance policy if you experience a change in your health prior to your departure.

Advice from our experts: No matter the reason behind a condition not being stable anymore, the time and money spent to modify your policy will definitely be worth less than costs for visiting an Emergency Room in the United States.

See the real cases of Mr. Sorry and Mrs. Right

Mr. SORRY

Total claim costs: more than $12,800 USD

Mr. Sorry suffered from COPD and high blood pressure. He applied for insurance without telling us about the many tests he had undergone in the 6 months prior to his departure, because of new cardiac symptoms. His physician had him perform many tests and then referred him to a cardiologist, who recommended a myocardial perfusion imaging. However, this needed to be done later because Mr. Sorry was now too close to his 45-day visit to friends in California. The procedure would wait until he came back.

While on his trip, Mr. Sorry had a massive heart attack and passed away. Unfortunately, that claim was denied because the client’s cardiac condition had not been stable and controlled for a period of 6 months prior to his departure. The family had to pay for the medical expenses incurred and repatriation of the body. Claim costs exceeded $12,800 USD.

One can assume that this could have been prevented if Mr. Sorry had had the suggested test before his departure, and had he waited until the 6-month stability requirement had been met before leaving on his trip.

Mrs. RIGHT

Total claim costs: $6,200 USD

Mrs. Right was 68 years old and suffered from asthma. She was planning on going to Mexico for 90 days. She purchased her insurance early to take advantage of the Early Bird discount.

Two months prior to her departure, her physician changed her medication for her respiratory condition. She could not change her departure date because she wished to attend her niece’s wedding, but she didn’t want to travel knowing that her unstable pre-existing medical condition would not be covered. She phoned her broker and explained the situation. The Reduced Stability Period option was offered to her at a reasonable price. The modification was made on her insurance policy and Mrs. Right left for Mexico on the scheduled date.

While on her trip, she needed to consult in an Emergency Room. The surcharge (less than $300 in her case) to get the Reduced Stability Period option was well worth it when compared to her $6,200 USD claim for that short visit to the ER!

Rule #3: Call Emergency Assistance prior to any consultation or treatment

Calling Emergency Assistance before any consultation or treatment is one of the most important rules to follow. We have signed contracts with many clinics and hospitals. Heading towards the proper approved facility might prevent you from having to pay fees upfront. It also allows us to accompany you through this difficult time, and to make sure that all of the recommended procedures and tests are necessary for your condition and will be covered. (We remind you that travel medical insurance covers sudden and unforeseen events. See the definition of “emergency” in the policy for details.)

Having Emergency Assistance by your side right from the beginning will facilitate the claim treatment. They are there to help and provide support in various ways:

  • Help you locate a physician, clinic or hospital;
  • Coordinate your medical treatment and keep your family informed;
  • Confirm your insurance coverage to the hospital and/or physician;
  • Guarantee or arrange payment to the hospital or physician, whenever possible;
  • Arrange for your repatriation to your province of residence if needed.

Advice from our experts: Calling Emergency Assistance before any consultation or treatment is mandatory. Your policy contains payment limitations. If you are in a position to call Emergency Assistance but don’t do so, your coverage could be very limited! If your condition prevents you from calling (if you are unconscious, for example), having your policy wallet cards with you at all times will help your traveling companions and/or the medical staff to reach us quickly, so that we can get involved as soon as possible. Your travel insurance includes a complementary emergency medical assistance service: use it!

See the real cases of Mrs. Sorry and Mrs. Right

Mrs. SORRY

Total claim costs: $4,500 USD

Mrs. Sorry was all excited about an upcoming trip to Florida to visit her grandchildren for the Holidays. When lifting her heavy suitcase from the belt at the airport, she injured her wrist but thought nothing more about it. “It will be fine tomorrow morning” she thought. But the next morning, her wrist was very swollen and painful. She inquired at the hotel front desk and they informed her that they dealt with a doctor that offered house calls. He was there in less than an hour… but presenter her with a $4,500 USD bill for that short consultation!

Mrs. Sorry should have phoned Emergency Assistance instead of inquiring at the front desk. Our agents are ready to help you and direct you to clinics or Emergency Rooms that are equipped to deliver the services your condition requires. We have relationships and contracts with numerous physicians and specialists. Our Emergency Assistance agents are trained to evaluate your needs and refer you to the most appropriate clinic or office. For example, if we feel X-Rays will be necessary, we will send you to a clinic that offers that service.

Because Mrs. Sorry was in a position to call Emergency Assistance but didn’t do so, we reimbursed her only $600 USD, corresponding to the value of such consultation, had the service been rendered in a clinic from our network. If Mrs. Sorry had phoned Emergency Assistance, she would have been referred to a clinic within walking distance from her hotel and the bill would have been sent to us directly.

Mrs. RIGHT

Total claim costs: $550 USD

Mrs. Right had been feeling sick for a few days. One day, she was coughing nonstop and running a fever. A retired nurse on the campground told her to go to the ER for examination and to be prescribed antibiotics. She even offered to drive her, as the hospital was 15 minutes away.

Mrs. Right decided to phone Emergency Assistance before leaving for the hospital. We asked her a few questions and directed her to a network clinic across the street, where X-Ray services were available. It took less than an hour and she was back home with the much needed antibiotics to treat her acute bronchitis. The $550 USD invoice for those services was sent directly to our claims department for full payment.

If Mrs. Right had not phoned Emergency Assistance and gone to the hospital, she would have incurred close to $4,000 USD worth of medical expenses, and would have only received $550 USD in refund of her claim. The decision to call Emergency Assistance was definitely worth it!

Emergency Assistance is there to assess the situation and direct you accordingly, taking everything into consideration, even saving you money! Phoning Emergency Assistance is ALWAYS a good decision!

Rule #4: When in doubt, ask questions!

You should never leave your province of residence without understanding your insurance contract. We provide you with an insurance policy and strongly encourage you to read it before your departure. Our confirmation letter highlights the most important points that need to be understood prior to your departure. We understand you are not an insurance expert, therefore if you have a question or need clarification about your coverage, your broker or our customer service agents are ready to provide answers.

  • Are you pregnant?
  • Will you be participating in a particular activity during your trip?
  • What happens if…?
  • Advice from our experts: There is no such thing as a dumb question. Better be safe… than have to pay!