I read a lot of opinions on this question all the time. Insurance is a complex area. Insurance can be one of the most expensive “optional” costs of a trip. Lots of people will have experienced issues getting a claim denied. I don’t think you really appreciate the importance of having travel insurance until something goes wrong !
I have some experience in this area and want to share my thoughts and ideas with you. I have never worked in Insurance and this is just based on my experiences. You should always read the T&C’s and get advice when required.
A few years ago, when my Parents visited me in Los Angeles, my Father had an accident. He was seriously injured and required emergency surgery. He was in hospital for 6 weeks and eventually was repatriated to Ireland. Medical care in the US is extremely expensive and thankfully he had insurance. He had notified his Private Health Insurance company of the holiday and also had purchased a separate travel policy. The Irish health insurance company (VHI) was extremely easy to deal with. The policy with them covered €250k for emergency treatment, which won’t go far in a serious situation. It also covered his repatriation home (more details below). However, we had considerable issues getting the claim covered for the additional Travel Policy even though it outlined a 7 figure cover.
In my experience, if a company can get out of settling a claim – they will. The onus will be on the beneficiary to prove that the claim is valid.
The following is my advice on how to deal with an Insurance Company, should you need to:
- Ensure all information is correct before you purchase a policy. These include, but are not limited to:
- Personal details
- Details of the trip
- Activities covered and not covered i.e. hikes to certain locations, extreme sports etc may not be covered
- Impact of weather conditions and so called “Acts of God”
- Bring your policy to the hospital or medical facility. Be very transparent with them regarding the details. In most countries they have an obligation to provide emergency care, before the insurance is validated and usually will do so. However, once a patient is stable and there are options regarding care, cost will become a factor.
- It is important that the Medical facility staff are on your side, accept your insurance details and will start communicating with the Insurance Company
- Be very careful about what you sign during this time. A hospital may ask you to sign “a medical power of attorney” if the person isn’t deemed able to communicate for themselves. You then can become personally liable for a debt. I had to sign this when my Father was initially admitted, but I didn’t sign it when he was re-admitted as he was conscious (more details below)
- Ensure the Insurance Company is aware of who will be their contact, relationship to the injured party and your preferred method(s) of communication i.e. mobile phone, email etc.
- Don’t be surprised if they don’t follow this and call a landline or write to a postal address. In my experience this can be a “tactic” to delay or confuse you
- Ensure you make it clear that they are not to contact the injured party directly. Tell them this is to ensure they concentrate on their recovery
- Document every interaction with an Insurance Company. I guarantee you that they will. They may record your conversations or summarise conversations. Summaries can be open to interpretation, which is why you need to document everything
- Try not to be emotional (which is extremely hard in this situation)
- Be factual and concise at all times
- Have a trusted friend or family member assist with communicating with them if they are in a different time zone. However, ensure you are both consistent and that they document everything i.e. copy you on email etc
- Email is your best friend when communicating with an Insurance Company
- Add “read” receipts
- Send a summary of a phone conversation. Ask them to reply back, correcting anything they didn’t agree with or confirming everything. Add if you don’t hear from them you will assume agreement (within a reasonable time period)
- Reread your emails before you send them, or have a trusted person read them. Do this when you think something may be open to interpretation
- Avoid sending anything when you are angry or upset (this can be difficult). Sleep on it and read it the following morning
- Keep notes on every interaction with the hospital and insurance company. Bring your notebook everywhere.
- If a claim is denied, firstly don’t panic and secondly communication then becomes even more critical
- Do not pay the hospital or medical facility anything when this happens. If you do, the insurance company may use this against you
- Send them an email or registered letter, acknowledging their refusal to pay the claim. Ask for a detailed reason why
- Wait until you receive their reply and then reply very factually why you don’t agree
- Provide brief details of why you think the claim is valid. This is where your detailed notes and written communication will be crucial
- Do be prepared that their instructions may be contrary to medical advice. My Father was discharged after 5 weeks, on the basis that he would remain in LA and attend outpatient rehabilitation services. My house was reviewed and we were provided with some items (wheelchair, walker etc.)
- The Insurance company said that my Father should fly home the day he was discharged. They left a message regarding this on my landline 2 days after he was discharged. I had called them the day before he was due to be discharged, but no-one was available to discuss his situation with me
- My Father became very ill 3 days after leaving the hospital and was re-admitted. He was in hospital for 5 days and had lots of tests. This is the portion of the care that the Insurance Company refused to cover (a 5 figure sum)
- Wait until you receive the reply. You always have a right to challenge their findings and the 2nd communication will usually be the most informative
- Once you review this, you will have some decisions to make:
- If they are correct and have identified an issue don’t panic
- Personally I wouldn’t accept the 2nd reply unless something very black and white is identified i.e. policy had expired, policy didn’t cover the event causing the injury, a prior medical condition impacted the injury etc.
- You could then decide (depending on the monetary value of the liability) if you should seek legal advice. You need to decide if its worth it financially
- I had to engage a lawyer for a different situation (I had an accident myself a year later). While the lawyers fee was 30% of any claim, they agreed not to charge me anything if a claim wasn’t successful
- Do not underestimate the time you will still spend, to support a legal process. The lawyer will bring the legal expertise and the muscle but you will have to provide them all the details and check all their communication
- If they are correct and have identified an issue don’t panic
- Once you review this, you will have some decisions to make:
- If you really think you don’t have any recourse with the insurance company, then request a meeting with a senior person, at the hospital, responsible for payments:
- Explain to them that the insurance company has denied the claim
- Don’t commit to paying the full amount but ask them if they will accept a lower personal payment
- They will often suggest a sum to resolve this quickly
- You might be surprised at how much lower this will be, but don’t commit to their offer
- Offer them a figure you can afford but one lower then their offer and see what happens
- If you don’t want to employ a lawyer and are confident that you have good documentation, continue to manage this yourself. I did that and I have no legal expertise but I am organised and had a lot of notes and emails.
- Send a very detailed written letter (hard copy) to them with details from your notes and emails
- They will overwhelm you with documentation so now you do the same
- Ensure you send it via registered mail
- Be very careful that everything you send is a clear concise record and nothing is open to interpretation
- Be very confident and assertive but not aggressive. Don’t threaten them with legal action
- You need them to know you are not accepting this and feel you have a strong case
- Be patient !
- If they still refuse the claim but provide nothing to contradict your information, but just repeat themselves, you now have a decision to make
- Do you engage legal assistance?
- Is there an independent forum or authority to support you with this claim? This is the route I selected and I engaged the Irish Insurance Ombudsman. I wrote them a detailed letter, enclosed the policy and copies of correspondence
- I stopped communicating with the Insurance Company
- After a few months the Ombudsman replied back. They said they agreed the Insurance Policy was valid and that we had recourse to review this further
- They offered 2 options:
- Mediation with the Insurance company. They said this would be a quicker process and that any outcome was legally binding and could result in a smaller payment being due to the hospital
- They would complete a longer detailed review, which also was legally binding. This was the option I selected
- They told me not to communicate with the Insurance Company in any manner and they would now manage all communication
- If they still refuse the claim but provide nothing to contradict your information, but just repeat themselves, you now have a decision to make
- It was 18 months before I received the ombudsman’s decision. During this time the Insurance Company did send me 2 letters and they also wrote to my Father in Ireland. I hadn’t told him about the Insurance issue as he was still recovering. He told me about the letter when I called him one evening. Thankfully my sarcastic and good humoured Father didn’t let it upset him. I assured him I wasn’t worried and had the time to spend on it. His initial suggestion was that I should tell them he died ….. after I stopped laughing and said I wouldn’t do that, he had another suggestion. He said I should tell them I don’t have anything to do with him, due to all the problems he caused. He told me he would ignore them and he wasn’t the slightest bit worried about them contacting him for the debt.
- The good news I have to share is that the Ombudsman agreed that the Insurance company was liable. They sent me a 23 page document. They had reviewed everything I sent and matched that to the insurance company’s documentation. It was very interesting how little information the Insurance Company provided to them. They included a really nice letter saying that Insurance Companies need to be more compassionate when something goes wrong and that they can’t override medical advice. They confirmed they were liable for all his treatment costs. This included the 2nd disputed 5 figure sum. They also sent us a cheque for €750 as a token !!!
- I want to add a note on Repatriation. Once my Father was fit to travel home (it was about 2 weeks after he was discharged the 2nd time, he was still weak but he wanted to go home and the surgeon agreed he could). I contacted his personal health Insurance company and they told me the following:
- They would firstly contact the surgeon to confirm he approved my Father travelling
- A nurse would be sent to accompany him on the journey and that they would both fly business class. The nurse arrived at my house and assessed my Father the night before we travelled
- The pilot, on behalf of the airline, had to review all documentation and approve him travelling
- An ambulance would meet the plane and transport him (alone) to his home
- They would pay for my Mother to travel also but she was to fly economy
- I flew with my Mother and I was able to upgrade us both using airmiles
- The ambulance personnel let me travel with my Father from the airport to his house
I know this post is long, detailed and contains personal information. But this is a very tricky area. While I hope none of my readers have something like this happen, if it does I do hope this may help you. I am purposely not naming the Insurance Company but they are a global household name.
Good luck, always purchase insurance, read the small print and do not accept an initial “no” to a claim that you believe is valid. Document everything and seek help when needed !