This post, aimed at Canadians, is something I couldn’t write while I was employed as a claims examiner. Now that I am not, I am eager to share the tips and tricks that can help you avoid some common mistakes people make when it comes time to use the insurance they take out to cover them while traveling outside their home province.
There are two ways you can obtain travel medical coverage. You either already have it as part of a group insurance plan, such as through an employer, union or association of some kind, or you shop for your own via the yellow pages, internet or a broker.
Tip #1 – If you do not already have out-of-province travel coverage through a group plan and are looking to buy a plan for yourself or your family, I highly recommend that you go through a broker. The reason I recommend having a broker is that if you run into trouble down the road in getting a claim settled, the broker is someone you can call up and say, “Hey, you told me that X company was the way to go, but they are giving me problems with my claim. Help me.” The broker will then gather information from you about the situation and will call the underwriter or third party administrator (the company contracted to adjudicate the claims) to advocate on your behalf.
That said, not all brokers wield the same leverage with the claims department. At each of three insurance companies where I’ve worked, we in customer service and claims were made very aware of the names of the top producers. The producers who bring in the most clients are very valuable to the insurance company, and so the carrier wants to keep them happy, doing whatever they can to cultivate and preserve that business relationship. Where I last worked, we called them our Platinum Brokers. I kept the list of their names on the wall of my cubicle. If one of them called me up to ask for a favour, I dropped everything I was doing and said, “Yes, Ma’am!” or “Yes, Sir!”
If you want that extra edge at claims time, first gather some phone numbers of travel insurance companies, which you can do via the internet. Call them up and just ask them who their top broker is in your area for travel insurance. Then call that broker and say, “I want you to be my broker.” If they shop around for you and steer you to a different carrier for your policy from the one who gave you that name, call that carrier’s travel claims department and ask, “Is SO AND SO one of your top ten producers?”
Now I’m not saying you can get a bogus claim paid by having a top broker in your court, but I’m saying that if you get in an iffy situation where there is some grey area, having a heavy person going to bat for you can make all the difference between a denial and having a denial overturned on appeal.
Tip #2 – Be honest when answering the application questions. I mean 100% honest. You may think you can hide things from the insurance company, but you can’t. They have ways of finding out. I’ll give you an example of how dangerous it can be to lie or even fudge a little bit when answering the questionnaire.
There was a woman who said no, she had never been diagnosed with heart disease, diabetes, a kidney disorder, blah, blah, blah through a long list of questions about her health. She got down to Florida and ended up with a very serious health crisis. As you know can happen if you have ever been treated in the good old US of A, the hospital bills were astronomical. We’re talking hundreds of thousands of dollars.
The first thing the claims department is going to do with any claim over a certain dollar amount is get your past medical history from your GP and any specialists to whom you’ve been referred in the past x years (usually three). They are going to go over those chart notes carefully to ensure you didn’t lie on your application. If your claim is really high (say $10,000 or more), they might ask the province for your entire health chart going back the same number of years. This means that the insurance company will have access to records for every medical visit for which you used your provincial health card, including walk-in-clinics. They will see in the notes if your doctor recommended some medicine, action or lifestyle change and you were uncooperative, which may invalidate coverage if your claim relates to the same area of health. They will see referrals to specialists and will then ask you for a release form to seek the charts from those specialists.
If they find that you lied on any question, your entire policy can be invalidated, your premium refunded, and you can be stuck with that $250,000 USD hospital bill for the lovely bypass operation and air evac, appendectomy or whatever. The best lawyer is not going to get you out of that mess. You lied, your policy is void; sorry, Charlie.
So again, do not lie. If you are not sure whether something qualifies as “a condition” or “been treated for,” just ask the person who is having you fill out the form, or who is reading you the questions over the phone. Tell them what’s up and say, “so do I check yes or no?” Keep a log of what day and time you asked that question. If you are later nailed and told you answered incorrectly but have proof you were advised to answer that way by a doctor or sales person, you have a very strong basis for appeal. Since the company will have recorded the phone call, all you need is the time and day for them to be able to pull the audio of the sales call.
Also, there is no need to lie since you can still get coverage in spite of bad health so long as the condition has been stable for a certain period before the trip. This is all laid out in the policy booklet. One thing you can do on your own or with a broker is examine a variety of policy brochures looking for differences in the stability period for pre-existing conditions. There are also plans out there with no health questionnaires to fill out. Those usually come as riders on your home insurance policy, so look into those if a health questionnaire is something you don’t want to have to go through.
Tip #3 – Read your policy. All of it. Especially read the small print. Be sure you thoroughly understand the concept of pre-existing condition. If you don’t understand part of it, call the sales person or broker to have it explained to you. If your broker ever says to you something like, “Oh, don’t worry about that. That really just means so and so…” then you need to document that phone call or office visit. Keep a journal of when you spoke and exact words that were said. Having a recording of the call is even better.
Watch out for myths. It is not true that you can’t get travel insurance if you have a pre-existing condition. You still can get insurance for a higher premium so long as that condition is “stable and controlled” before the trip. Make darned sure you understand the concept of stable and controlled. If you read the policy booklet and talk to your broker and still are not comfortable, call the claims department and ask an examiner, “if I end up with a claim for this acting up while I’m away, will that be covered?” Some examiners are not allowed to answer hypothetical questions like that, for the obvious reason that each situation is different once it happens with all its myriad variables, and they don’t want to get caught having to pay an invalid claim because “so and so told me it would be covered.” But some examiners will have such a discussion with you. If one won’t, call back and see if a different examiner picks up the phone. Or ask to speak to the claims supervisor, who might be more willing to go into hypotheticals with you. If she/he won’t, see if you can be transferred to the Assistance Team’s supervisor, who will likely be an RN who knows the policies inside and out. Again, keep a log of when you spoke to the person, how to spell their name, their extension number, and the exact words you were told.
Tip #4 – Go over the policy again right before your trip. Highlight any things you might forget, like the deadline for filing.
Tip #5 – Put the wallet card in the wallet you’ll take with you on the trip and USE IT. In fact, if you will be traveling to an area from which it may be difficult to make a phone call, such as Mexico or a jungle somewhere, go ahead and get the email address of the claims department, as well. If you run into ANY trouble at all during the trip, call the toll-free number on the card or, if you can’t call, try to find an internet cafe so you can email. You can also call collect or, if it’s your only option, call from your cell phone and submit the bills later as part of your claim.
Most policies say that you must call in the event of a medical emergency. So know the definition of medical emergency. Some people take this to mean they only have to call immediately if they go to the emergency room or urgent care clinic, but don’t have to call for something routine like a cold or flu. Yes, you have to call for anything for which you will later be claiming. In fact, you should also call about things that you cannot claim or do not plan to claim. Keep the carrier informed every step of the way regarding what is happening with your health. This is because most companies these days employ something called managed care. They have nurses on the phones 24/7 whose job it is to help you find a nearby clinic or hospital, review why you are seeking medical care and whether the level of care is covered, warranted, etc. The assistance team is there to help you, including to warn you of anything that might not be covered on the policy. They are there to protect you from any unpleasant surprises…like a lab test or invasive procedure that may not be seen as necessary. The treating medical team and the nurses on the assistance team will work together to make sure you get the best care possible, but they will also work to decide whether the care should take place in Canada or where you are vacationing. Even if the medical emergency is not for some reason coverable, the assistance team will still assist you all the way through the emergency, including providing live interpretation of foreign languages if necessary. You paid for the services, you have a right to use them.
So again, call as soon as you know you’ll be seeking medical attention. You may be in Mexico, where it is a real hassle to make international phone calls, and think seeing the hotel MD about your sniffles is no big deal, you’ll tell the insurance company when you get home. Wrong. Go ahead and do your best to call (or email) as soon as you can. One reason is that you never know what that cold might develop into later. You want to have the assistance team in the loop from the get-go. If you can’t call before being treated, call or have someone call on your behalf as soon as possible. This is really important for getting your claim paid.
Tip #6 – Follow the instructions of the Assistance Team. They will guide you through the whole process step by step as your medical emergency unfolds and will check with you as you start to feel better to make sure any medication is working. They will advise you whether any follow-up visits are covered and what to expect next. They will tell you when and how to file the claim, either on a paper form that they are mailing out to you, or online. They will remind you of any claims filing deadline. If they don’t, ask.
If at any point you feel the assistance team member is not acting in your best interest or is not providing you with a good service experience, do not hesitate to ask to speak to the person’s supervisor. I know medical emergencies are stressful, but do your best to stay calm and speak respectfully to the supervisor when you outline the ways in which you feel your case is not being handled well. You might be able to request a different examiner or assistance person.
If you really are having trouble seeing eye to eye with the assistance team, bring your broker in the loop.
Tip #7 – Follow instructions to the letter when submitting the claim. This means filling the form out completely and honestly and filing in a timely manner (some policies have a 30-day window, some a 90-day window for claim submission). Some companies start counting when you get home, some start counting from the date of incident. It means filling out the forms properly and fully. It means submitting ORIGINAL bills and, for annual polices, proof of your departure date.
If there is any part of the form you don’t understand, call the claims department and ask to be walked through it. That’s what they’re there for. Go over with them everything you are putting in the envelope and ask, “Is that everything?” A quick call of this type can save you the unpleasant experience of having it all returned to you to redo.
One mistake a lot of members make is thinking that direct billing means they don’t have to file. Often the Assistance Team will be able to convince the doctor’s office or hospital to bill directly so that you don’t have any out-of-pocket expense at the time of the emergency. This does NOT mean you don’t still have to fill out the claim form. You do. Direct billing just means the bills will be sent directly to the carrier for adjudication.
Tip #8 – Don’t take no for an answer. Let’s say you messed up and didn’t send in your claim form by the deadline, so your claim was denied. Or let’s say you forgot to tell the sales person about that little asthma attack you had two weeks before departure, which they are now saying constitutes your pre-ex not being stable and controlled. There are many things you can do to mount an appeal to a denied claim.
- Call your broker and ask for his/her intervention. Often this is all you will need to do, as the broker will help you through the appeal process. In fact, it may not even get as far as a formal appeal. Depending on the size of the claim, one phone call by a star broker might be all it takes.
- If you don’t have a competent or helpful broker, call up and ask what the process is for appealing a claim decision. Ask the advice of a claims examiner. Say, “If you were mounting this appeal, what would you include?” Most claims examiners are people like you and me. They enjoy being able to approve claims and don’t like having to deny them. Most will help you out, feeling more sympathy for you than for the corporation they work for.
- Read over the policy again to make sure the decision made by the claims team is 100% supported by the wording of the policy. If the policy doesn’t clearly spell things out, the denial should be overturned. Never assume that the claims department or assistance team understand the policy better than you do. They know what it is supposed to communicate, but you know how it sounds to you. I can’t tell you the number of times we examiners disagreed on the true underlying meaning of a clause versus what it actually said. If we couldn’t agree, then there is definitely room for appeal!
- Ask yourself what went wrong and why. Is it your fault, or did someone mislead you? Here is where those notes come in handy regarding who told you what at what time on which day. Insurance and sales companies record phone calls, so pull out those notes and ask to have the tapes pulled. Are there extenuating circumstances you feel should be taken into consideration? If so, write out why.
- Get supporting documentation for an appeal. If the carrier is telling you that you lied on the application by saying you did not have a heart condition, a letter from your doctor stating that a bundle branch block is not “a heart condition” can go a long way toward having the denial overturned. I remember a case where a family was going to lose their house because their little girl had had an upper respiratory infection within the 90 days prior to their trip and got down to the US and had a situation that turned into a hospital stay with lots of costly intervention (those MRIs and CT scans add up fast). It had never occurred to them that a cold was a pre-ex. Fortunately, they turned to their family physician for help. This kind doctor wrote a letter that not only mentioned the horrible financial situation this unpaid claim had put the family in, but also testified that the child could easily have picked up an entirely new bug on the plane or at Disneyland. One was not necessarily linked to the other and there certainly was no medical way to prove that the second crisis was a continuation of the first. I was the lucky examiner who got to call the mom and say, “your appeal has been approved, the denial overturned.” She lost her composure right there on the spot. We both needed tissues!
- Don’t hesitate to remind the company of your standing as a customer. If you have been a loyal purchaser of this brand of insurance for 5 years or more and this is your first claim, say so.
- If you need further advocacy beyond your broker, contact the ombudsman for life and health insurance in your province. In Ontario, that’s http://www.olhi.ca/. In fact, sometimes just saying you are about to contact the ombudsman will get results.
- If the claim is large enough, consider retaining a lawyer.
In all the time I worked as a claims examiner, I noticed one trend over and over. The squeaky wheel gets the grease. People who appealed politely but firmly got the best response, followed by people who appealed less politely but still with firm and rational grounds behind the appeal. There was even one man who was not polite and actually should never have had his claim denial overturned, but managed to get a small concession simply through persistence. He was eventually told that if he continued to call, it would be considered harassment and we would have to start hanging up on him, but before it came to that, he did manage to get a couple of bills paid that really were solid denials.
A final note about brokers: although I highly recommend having one, in my experience they are not the ones who really know the policies inside and out. I had many, many cases where the client, when caught not having followed proper procedure to ensure full coverage, said something to the effect of, “But my broker said I didn’t have to call first unless….” or “my broker said I was covered for everything,” or “my broker said I could just send everything in once I got home.” Remember that the broker is trying to make a sale and sometimes will sugar coat some processes to make things sound easy-peasy, please just sign on the dotted line. When in doubt, call the claims department or assistance team yourself to verify what you’ve been told by the broker.
For more tips on how to mount the most effective appeal, have a look at these articles, with which I agree wholeheartedly:
If you have found this article to be helpful, I hope you’ll leave a comment to let me know. Cheers and happy travels!