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Common Reasons an Emergency Medical Travel Insurance Claim May Be Denied

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Perhaps you’ve seen a similar segment on the news – a reporter is at a busy airport asking travellers, “Do you have travel insurance?”. The response is a mix of proud yeses, peppered with a few regretful noes. The segment ends with a reminder to purchase travel insurance as people hurry about in the background.

While purchasing travel insurance is a first step in financially protecting oneself from sudden and unforeseen accidents and sickness, understanding your health, your trip, and the terms and conditions of your policy may be even more important.

Below, we’ve provided 4 examples to illustrate why a claim may not be payable to help you recognize the importance of understanding the terms and conditions of an insurance policy. Each example ends with a tip to help you better understand how a policy’s benefits, terms, conditions, and exclusions may impact an emergency medical claim.

1. Not a Sudden and Unforeseen Event

Travel insurance is designed to provide travellers with coverage against sudden and unforeseen events. This means the traveller had no way of knowing the emergency sickness or injury, which caused them to submit an emergency medical claim, was going to happen.

A medical emergency, resulting in a claim, is not considered ‘sudden and unforeseen’ if there is medical evidence that shows the insured experienced symptoms prior to the effective date of coverage and within the stability period (for policies with coverage for pre-existing conditions).

A stability period is a predetermined period of time, stated in the policy wording, in which there must be no changes in medications or medical conditions, including recurrence, for the insured to be eligible for coverage.

Stability periods may vary from provider to provider.

Consider the following example:

Chen is visiting Canada. He awakes one morning feeling ill and realizes he needs to see a doctor. Chen does not have emergency medical insurance and knows that medical care can be expensive.

His son purchases a Visitors to Canada Emergency Medical Insurance policy for him online that morning. The next day, Chen visits a walk-in clinic and the doctor prescribes antibiotics for bronchitis.

Chen then submits a completed claim form along with the original receipts for the medical appointment and the prescription.

When a letter arrives from the insurance company, he learns his claim is not payable. Chen’s medical records from the walk-in clinic indicate he had been experiencing symptoms prior to purchasing the policy. This demonstrates Chen knew he might need to make a claim prior to purchasing the policy and therefore his claim was not sudden and unforeseen.

Tip: Emergency medical insurance coverage is available for sudden and unforeseen medical emergencies, as defined in the policy. If you are unsure about the benefits, conditions, terms, and limitations of the policy you are purchasing, speak with a licensed insurance broker.

2. A Pre-Existing Condition

A pre-existing condition is another one of the most common reasons why a travel insurance claim may be denied.

Generally speaking, a pre-existing condition is a medical condition (other than a minor infection) which existed prior to your effective date and includes a medically recognized complication or recurrence of a medical condition. The definition of a pre-existing condition may vary depending on the insurance company.

Consider the following example:

Priya travels to Canada to visit her sister. While in Canada, Priya experiences dizziness and vomiting. She is hospitalized and treated for her symptoms.

Priya submits her completed claim form and the required supporting documentation.

The claims examiner finds that the attending physician’s notes from the medical emergency, paired with the notes in Priya’s medical records (from her home country), show Priya’s dizziness and vomiting are related to a pre-existing condition, vertigo. It is determined that the condition existed prior to her effective date of coverage and she sought treatment for it before departing on her trip.

The policy Priya purchased does not provide any coverage for pre-existing conditions what-so-ever. Therefore, in this example, Priya’s claim is not payable. While she is aware the travel insurance policy she purchased does not cover pre-existing conditions; she did not take her pre-existing condition into account.

Priya had not considered her past visits to the doctor worth mentioning because she had received treatment for her vertigo and was feeling fine when she purchased the policy. Because Priya had said she had no pre-existing conditions, a plan was recommended which did not offer coverage for pre-existing conditions.

Tip: Having a clear understanding of what a pre-existing condition is, the terms and conditions surrounding pre-existing coverage in a given policy and how they relate to your medical history, will help you to choose an insurance plan that is right for you.

While you may feel fine, your medical records may not support your claim. If you are not sure about your medical history, consult your primary care physician.


3. Policy Exclusions

Policy exclusions are another common reason a claim may not be payable. Policy exclusions are provisions within the insurance policy which eliminate or restrict coverage for certain types of risk. Exclusions may apply to the benefits, and other areas, of an insurance policy.

Consider the following example:

While on holiday, Patricia goes skydiving. During the landing, she injures her wrist. She is taken to the hospital, by ambulance, and is diagnosed with a broken wrist.

Patricia submits her completed claim form along with the supporting documentation and original receipts.

She learns her claim is not payable because her injury was sustained as a result of skydiving. Under the policy she purchased, there is no coverage for ‘Extreme Activities’, including skydiving.

Tip: Various activities may be excluded or limited under your travel insurance policy. Before purchasing an insurance policy, make sure the activities you’ve planned for your vacation are covered. Take a few minutes to review and understand the policy wording. Contact your licensed insurance broker or the insurance provider for clarification.


4. Policy Limitations

Many emergency medical travel insurance policies allow a maximum amount of coverage for certain benefits. These limits may be per claim or over the entire duration of the policy.

Consider the following example:

Amy experiences acute dental pain and suffering not related to an accidental injury and visits a dentist for treatment. She submits her claim, along with the necessary supporting documentation. Upon review of the policy wording, the claim is paid in full.

A few weeks later, Amy again experiences acute dental pain and suffering not related to an accidental injury and unrelated to her previous claim. She visits a dentist for treatment. She submits the claim.

This time, Amy receives partial reimbursement. She learns that her expenses have exceeded the cumulative maximum benefit limit for acute dental pain and suffering not related to an accidental injury under her policy.

Tip: Understanding the benefit limits of your policy will help you to understand how much coverage you are eligible for, for each benefit, under your policy. Each policy will have an overall limit and may include sub-limits for some categories of coverage.

When purchasing a travel insurance policy, it is imperative to provide complete and accurate medical history and to take the time to read and make sure you understand your policy.

Understanding the policy you’ve purchased will help to make sure you’ve purchased a policy, which meets your needs. So, in the event of a sudden and unforeseen medical emergency, you won’t have to worry about how you will pay for the expenses.

If you have any questions, speak with your licensed insurance broker.

For questions about Travelance policies, speak with your Travelance licensed broker or call 1-855-566-8555.

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