Don’t Give Reasons to Insurers to Deny your Claim

Don’t Give Reasons to Insurers to Deny your Claim

There is a myth that insurers routinely deny claims: This is a general feeling among masses that insurers honor claims of those only who fight back. The fact of the matter is that 90% of all the travel insurance claims submitted are paid.

But, it can be very frustrating for those who had been denied their travel insurance claim. So the first question arises that why the claims are denied??

In my experience, the biggest reason for claim denial is the customer’s failure to understand the terms and conditions of the policy and his/her inability to comprehend the technical language used in the policy wording.

When you buy insurance, you not only spend a few hundred dollars but you are also trying to save thousands of dollars which you may otherwise need to spend in case of medical emergency. Denied claims can ruin your financial well-being.

No doubt, buying travel/visitor insurance is the most important step in financially protecting yourself against any sudden and unexpected sickness and disastrous accidents but understating your trip plan, terms & conditions of the policy and in-depth knowledge of your day to day health is even more important.

Herein I will like to discuss few examples to demonstrate clearly to help you grasp the value of understanding the policy wording and terms and conditions.

Policy Exclusions: Generally insurance agreements are very wide, so to eliminate the coverage for certain type of risk the insurance company is unwilling to cover they use ‘exclusions’. In short the exclusions are statements in the insurance policy that explains a condition or type of loss which is not covered by the policy. As per the law exclusions must me written very clearly and they have to be precise and specific.

For example:

Linda has gone to Wakefield, Quebec to see her mom and suddenly she decides to do go to “The Rock” (Highest Bungee Jump in North America) to have a feel of bungee- jump. During the jump she injures her both the ankles and was taken to the hospital by ambulance.

Linda submitted duly filled claim form along with all the original receipts of medicines, x-ray and all other medical expenses, but she received a letter informing her that her claim is not payable because she sustained her injuries while she was involved in an “extreme activity”. In her policy under the exclusions section it was clearly written that extreme activities would not be covered including bungee jumping.

Moral: There are various activities which are generally excluded in most of the travel insurance policies. Before you buy a travel insurance policy, it will be a good idea to make sure that the activities you are planning to do during your vacation are covered. In case you are not able to understand the policy wording to your satisfaction, call your insurance advisor for further clarification.

Event could be expected or foreseen: The very purpose of travel insurance is to provide coverage for totally unforeseeable and unpredictable events. It means that the policy holder had no way to be aware of any future medical emergency for which he had to submit a claim.

Any medical emergency will not be considered unexpected and sudden if there is evidence that the insured felt or experienced symptoms before the effective date of coverage and also during the stability period.*

For Example, Chantale is visiting the USA and on one fine day feels very sick and she realizes that she has to see a doctor and she does not have medical travel insurance. Her brother buys Visitor to US Medical Emergency Insurance on line that afternoon thinking that that medical treatment in US can be very expensive.

Next day, Chantale visits the doctor and was prescribed antibiotics for UTI and was asked to undergo some tests.

Chantale kept all original receipts and attach them with her fully completed claim form and send it to the company.

Chantale receives a letter that her claim will not be paid as the records from the doctor office revealed that she was experiencing some symptoms prior to buying the policy. The company further explains that this proves that Chantale was aware of the fact that she might have to make a claim, so her illness was by no means sudden or unexpected.

Moral: – The emergency medical insurance is for sudden and unexpected medical emergencies and that is always defined in the policy. If you have any doubt, always call an expert insurance advisor to avoid any ambiguity.

Pre-Existing Medical Condition:This is one of the most common reasons for denial of the claims. In short we can say that a pre-existing condition is one which existed before the effective date of your insurance. I have talked about this term in length on our website bestsupervisa.ca

For Example: Harry came to Canada to visit his brother. His brother had bought a Visitor to Canada Medical Insurance policy for Harry. During his stay Harry developed severe chest pain and was to be hospitalized for five days. Harry’s brother submits the claim along with all the original receipts. After examining the claim details the claim department denied the claim saying that it was a pre-existing medical condition. Actually the attending physician notes from the Canadian hospital along with the medical notes from his home country determined that Harry was treated for a lung infection and his brother did not mention it to his insurance advisor at the time of the buying the policy so as a result he was advised to buy a policy without pre-existing medical condition. Here, both Harry and his brother were aware that the policy did not cover pre-existing conditions still he did not take his pre-existing medical condition into account and obviously was denied the claim.

Moral: you may feel fine at the time of buying the policy but your medical records may not support that feeling. If you are not very confident about your medical history, talk to your family doctor and discuss those facts with you insurance advisor so that he can guide you properly.

Limitations: Policy limitations may vary from policy to policy and they allow a maximum amount of coverage for certain benefits.

These limitations may be per claim or for the entire duration of the policy coverage which you must be aware of.

For Example: Rita has come to Canada on a leisure trip and during her stay she had a very piercing pain in her jaw and teeth. She was taken to a dentist and was treated with antibiotics and had to undergo a minor surgery as well. She submitted her claim along with all the receipts but her claim was not paid in full because under her policy the maximum coverage for dental emergencies was $ 500 and her total bill was for $1400 so she had to bear the burden of $900 herself, which was a huge sum considering that she was just a student and had no parental support.

Moral: It is always advisable to understand the policy limitations for each benefit and decide accordingly if any need arises. There are many examples where visitors after receiving initial treatment have gone back to their home country much before their actual departure date as they could not bear the cost of the entire treatment just because of policy limitation on a particular benefit.

In nut-shell, we can say that spending time in thoroughly reading and understanding the policy wordings, term & conditions, exclusions is a must. This will prepare you to handle the situation in the most prudent way if any medical emergency arises. Secondly, it will also prepare you to get the policy which exactly suits your requirements.

Please provide complete and accurate medical history as this will enable your licensed insurance advisor to provide you with the best policy as per your needs, though, it may be a little expensive but no wise individual wants to look like a penny wise and pound foolish.

*This stability period is relevant for policies with pre-existing medical conditions and the period may vary from 90 days to 180 days.