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Travel insurance claim denied, denied, denied — oh, never mind!

December 29, 2009

Here’s a truly strange case, brought to you by the H1N1 virus and our friends at Access America.

You might say Marian Levin’s claim was denied on a technicality. An important technicality that I’ll get to in a moment. But it’s how her problem was resolved that’s even more interesting: Her travel insurance company turned down her claim and a subsequent appeal but then mailed her a check anyway.

All of which goes to show that if you don’t like the first (or second, or third) answer from a travel insurance company, just keep asking.

Levin explains what happened to her:

I bought trip insurance for a US Airways flight to Denver as my husband and I were going to visit our daughter and grandchildren.

We were scheduled to fly on October 22, 2009. On the afternoon of October 21st, my daughter called saying her six-year-old son had just been diagnosed with H1N1 and wanted to tell us so we could cancel our flight as she didn’t feel we should be around her son and she wasn’t feeling too well either. My husband and I agreed and called both the airlines and US Airways.

All the paperwork was received by Access America, including the physician’s report. Yesterday I was called by Access America telling me the claim was being denied as the physician was the patient’s father. I have looked through the booklet of coverage and cannot find where this is excluded.

My grandson’s father is an emergency room doctor and I asked her that if a relative were treated in an ER would that be an exclusion as well.

Is there any way you can help me out on this?

I’ve never heard of such an exclusion, and since Levin had received a rejection by phone, I thought it might be worth appealing Access America’s denial in writing. (Insurance insiders tell me that more than 90 percent of appeals are successful.) So that’s what she did.

Here’s what happened next:

I wrote to Jeff Hyman, a vice president of travel operations, and Jon Ansell.

A few days later I received a phone call from Justin Nichols, who was adamant about “the rules” about a physician treating any relative. I told him that in this instance the doctor who treated the patient was an ER doctor as asked what would have happened if the patient had been brought to the ER and this particular doctor was the only physician available? Justin told me the insurance company would not have paid.

I told him that “rules” sometimes have to bow to common sense and he told me that if I could get the patient’s regular doctor to say that the patient’s mother had called about the child’s symptoms (which were H1N1) the claim would be reconsidered.

I spoke to the pediatrician’s nurse and she said she’d see what she could do, but it would be at least a week as the doctor was away.

Today I received three letters from Access America. Two requested more information and the third was a check for $600.

Isn’t it nice when the right hand knows what the left hand is doing?

Yes, it is.

If Access America’s policy had an exclusion for doctors who happen to be relatives, Levin probably wouldn’t have had much of a case.

The insurance company did the right thing, although it may not yet be aware of it.

Update (11:45 a.m.): It is now. From a company representative:

I thought you might be interested in our definition of “Doctor” as stated in our travel insurance policies: Someone who is legally entitled to practice medicine, and is licensed if required. This can’t be you, a traveling companion, any member of either of your immediate families, or any member of the sick or injured person’s immediate family.

Despite this, I’m glad we were able to make a consideration for this customer.

(Photo: I’m not there/Flickr Creative Commons)

Christopher Elliott is the author of Scammed: How to Save Your Money and Find Better Service in a World of Schemes, Swindles, and Shady Deals. Critics have called it “eye-opening” and “inspiring” — it’ll “grab your attention and won’t let go.” Order your copy now on Amazon, Barnes & Noble or iTunes.

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17 comments

  • http://praguepartmentsonline.com Martin Smith

    This is a very common exclusion in all kinds of insurance and not just travel insurance.

  • Lisa S

    Here we have an example of people doing the responsible thing: buying trip insurance AND not exposing other people to H1N1. If the grandparents had gotten H1N1 while visiting and had to fly home while sick, a lot of people would have been very unhappy. And yet, Access America wanted to deny the claim. If it is a common exclusion not to accept paperwork from physicians who are relatives, it should be clearly written in the terms of the agreement. Moreover, Access should have said it simply needed information from a physician who was not a relative, rather than deny the claim. It doesn’t sound as if the grandparents were trying to get out of the trip; there were very real reasons for canceling the trip.

  • Cynthia

    Even if it is a “very common exclusion in all kinds of insurance” it needs to be stated in writing in the policy documents in a way that makes the policyholder aware that it exists. If it cannot be found in writing in the policy documents then it does not exist.

  • Joe Farrell

    And Martin, such an exclusion needs to be disclosed clearly. PRIOR to making a claim. In fact, if the policy is vague because it fails to disclose an exclusion to coverage later invoked, the policy is interpreted by the courts as if the exclusion does not exist – and the insurers know it as well. If it is the practice of the carrier to deny all claims except those which are appealed [which seems to be the case if 90% of the appeals are paid] then I would have some serious issues with the claims practices of that insurer.

  • Mike

    I’m sorry, but if the note or paperwork is coming from a licensed physician, then any claim or paperwork should be deemed valid. If the physician is found to be lying then the company has recourse with various boards or courts.

  • SirWired

    While I can’t speak to what the AA policy was at the time the OP purchsed, here is a snipped from the “Definitions” section of a current AA policy:

    “Doctor: Someone who is legally entitled to practice medicine, and is licensed if required. This can’t be you, a traveling companion, any member of either of your immediate families, or any member of the sick or injured person’s immediate family.”

    So, if that definition was in the initial policy, the denial was legit, and the override a common-sense courtesy.

  • Carver

    I’m going to side with Access America on this one. The policy appears to have been disclosed, perhaps in the fine print. But as a practial matter this is the sort of exclusion that is likely to affect a tiny minority of the policy holders. And the exclusion makes sense. If someone is sc, its probably not a big deal to get a regular doctor to sign off on the note. But I can understand Access America being concerned about family members basically getting a free pass because you have a doctor in the family.

  • dennis kavanagh

    Most states have “bad faith” statues against insurance companies for not treating their customers fairly. If a claim is turned down at the 1st level, be sure to assert “bad faith” at the 2nd level. That will get the ins. co. attention. Dennis K. in Calif.

  • Les

    @Chris:

    Is there a regulatory agency designated to oversee travel insurance? I’m aware of various state insurance commissions which regulate property and casualty coverage but I’m unclear on travel insurers.

  • SirWired

    Dennis,

    As covered in the updates, the policy explicitly includes an exclusion for treatment or diagnosis by family members. This is a sensible exclusion that is there for obvious reasons.

    Les,

    Insurance is a state-by-state product. Any complaints would go to the appropriate state insurance office. Some are better than others.

  • Jasper

    Another example of the insurance industry not doing their job: Insuring.

    I propose we merge the insurance industry with the gambling industry and apply the same rules.

  • Jason

    The funny thing is, its so easy to get around this ‘exclusion’. I am a physician. I have LOTS of physician friends. It would be extremely easy to get an MD friend of mine to fill out a form or write a note.

    So the moral of the story is to know the policy exclusions, and then make sure you know how to properly avoid falling into the insurer’s pitfalls.

    We do the same for calling in scripts to the pharmacy. My buddy and I will call in for each other’s families, and not our own, just to keep it a bit more kosher.

  • Joshua Z.

    I’ve used Access America for flight insurance on a trip I took a few years ago to Costa Rica and Panama. I mainly chose them as they had a “cancel for any reason” plan where I could cancel the flight and get 75% of the money back. I ultimately had to cancel the flights as the trip dates changed and we could not change the flights. However, once I canceled the itinerary, it took several months and a letter to them to get them to pay us. They could not confirm that the itinerary was canceled. I ultimately sent them a letter with screenshots of the page saying the itinerary didn’t exist, the seatmaps showing that my selected seats were now empty, and even the new itinerary for my trip, which I would not insure. They finally paid us, but I still don’t believe it was worth all the hassle.

  • Colin

    I wonder of the exclusion applies to Nurse Practitioners as well? Many urgent care clinics are exclusively staffed by NP’s, and if the case is too serious, the patient is sent to an ER. I know, my wife is an NP who primarily does urgent care. They are licensed, but are not doctors.

    Does anyone know?

  • kwoww

    This is a very common exclusion with insurance. Although I will be the first to warn against using Access America, I must say in their defense, you can’t help it if people don’t read their policies. The brochure you get from your agent is only a breif overview of your benefits and exclusions. You get the actual policy once you are insured, and it is very extensive. This is why most companies give you a “free look” period (usually about 10 days) which gives you the option to withdraw without penalty once you’ve examined your actual policy. It is certainly possible that this person was only reading the brochure.
    I would hate for a story like this to give Trip Insurance a bad name. It seems every time Chris writes about someone getting hassled by their insurance company, Access America is the culprit.

  • monalisa
  • Rita

    I always buy travel insurance. Mostly because my 82 year mother whom I care for can get sick at anytime and I am a Diabetic. Also the both of us are on a fixed income. Well my mother surprizingly died 2 weeks before our trip to DC for my sons wedding. I applied for reinbursement to Access America and sent them her death certificate and they denied me in one letter and said in another that I would get our money back.
    Then they sent me another letter asking for the doctor to fill out a form telling them how long she’d had the disease. I called them and told them this is rediculous ( Dead is Dead! ) and the death cert. notes what she died of which was Ischemic Colitis which is like a heart attack of the colon and her colon was dieing. They could easily look this up in a medical dictionary to find out what it was. It’s not a prexisting condition you die from this unless you are young, health and can have surgery for a colostemey. She was 82 and the disease for that is called ( Old Age ). I still haven’t gotten our money back.

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