Health Insurance Claim Denied? Don’t Take It Lying Down

The most common reasons insurers give for denying travel insurance claims are that the medical emergencies that were treated were pre-existing, or maybe you didn’t disclose everything on your medical record, or you selected the wrong policy in the first place. Or maybe you misunderstood the terms, or the agent who sold you the policy didn’t understand its exclusions—or maybe the agent didn’t show you the fine print and you just took it for granted that when he or she said “you’re covered for everything,” they meant it. But denials are not always final. Don’t take it lying down.

In my years of providing insurance ombudsman services, I have seen that the client is not always wrong and the insurer always right. And believe me, you can get a large insurance company to back down, to admit they may have made a mistake or overlooked some medical facts—or to admit their representatives might have done their job sloppily and not explained what they should have to you clearly and in plain language, or may have hurried to squeeze in one more sale before quitting time. Or maybe the questionnaire they asked you to complete was ambiguous or full of loopholes.

If you are told your claim is denied, don’t settle for a verbal conversation on the telephone or a form letter simply saying, “We cannot pay your claim as you are subject to exclusions.” Insist on getting a letter of denial specifying exactly why your claim was disqualified, the medical grounds for disqualification, and the medical evidence substantiating those grounds. Then verify that the information from the hospital records, the doctors’ notations, and your own doctors’ treatment notes are correct. Ask your doctor for help, if necessary. But be honest with yourself. What counts is the language in the policy—not your instinctive sense that you are being “picked on.”

Then, gather whatever documentation you have to dispute the insurer; complete your rebuttal in written form, but in plain language and using common sense (don’t try to play lawyer); and ask to have it presented to your company’s appeal committee. Ask to know who is on this committee and when you can expect their response. Ask if your insurance company has an in-house or independent ombudsman service (as it should). Present your information and get specific, itemized responses to each of the points you put forward. Don’t be vague and don’t let your insurer be vague. And keep track of all of your exchanges.

If at the end of this, your insurer persists in the denial and you still feel you have not been fairly treated (according to the terms of your policy—not just because you think “it’s not right”), take your case to the ombudsman service or insurance commission in your province or state. In Canada, visit OmbudService for Life & Health Insurance. Take these steps on your own before you hire expensive lawyers. You can always do that later if you still feel justified.

Don’t take it for granted that you can’t fight City Hall. You can. And sometimes you can win. I’ve seen it happen often, and each time I give up a little cheer.

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