It might be something of an understatement to say that the ski trip that Victor Thomas and his girlfriend Susie took in Zermatt, Switzerland, two years ago, did not go as planned.
On her first day on the slope, Susie fell and shattered her lower leg. She spent the rest of her vacation in the hospital.
Good thing Thomas had bought travel insurance through Access America — or so he thought.
The insurance company “did a great job at that time” he says, paying for the helicopter airlift, losses from trip cancellations and arranging and paying for a first-class ticket home, plus a limo ride back to her house, as specified in the insurance contract.
But …
We were not aware that there was a problem with payment of the hospital bill until we got a phone call from a Swiss collection agency in August of this year. Susie has Blue Cross and they immediately faxed the hospital a certification of coverage and a request to submit the bill while Susie was in the hospital and of which we obtained a copy at that time.
Blue Cross was to cover 80 percent of the $13,000 bill less a $500 deductible. Access America also guaranteed payment of the hospital bill up to the $10,000 medical limit of the travel policy to allow Susie to check out of the hospital. Susie was told by Access America in phone calls, also when she was in the hospital, that they would assist in getting the bill to Blue Cross.
Not to get all political, but doesn’t this sound like one of those case studies they like to mention on the news when discussing health care reform? It also brings up an important question about health insurance portability. But I digress.
The problem arose when the hospital’s billing office failed to bill Blue Cross and started billing Access America instead. In reply to several letters from Access America, Susie discussed the situation with them by phone and was assured that the matter would be taken care of.
We found out last month that Access America finally paid $9,688 (the $10,000 policy limit minus $312 in previously paid expenses) to the hospital on 4/23/2008, leaving an unpaid balance of approximately $3,000.
Then, on 5/15/2008, Blue Cross received a bill for $10,362 from the hospital, over two years after the hospitalization! Blue Cross denied the claim. On 9/3/2008, Blue Cross received another bill for the same amount from the hospital and this time the claim was accepted with Blue Cross agreeing to pay $9,573 of the amount.
So what went wrong? Somehow, Blue Cross paid the wrong party, sending the money to Access America instead of the Swiss hospital.
When I called Access America to inquire how to get them to pay the remaining balance of the hospital bill — about $3,810 — I was told to resubmit the claim for review, which I did.
A few days ago, I received a call from an Access America medical examiner and was told that the claim was denied. She said that since Access America had paid out the maximum $10,000 medical benefit, they were not liable for the remaining balance.
I asked Access America to review Thomas’ case again. And fortunately, it did.
We’ve researched this issue and Dr. Thomas is correct in that we paid the hospital in accordance with our guarantee of coverage. We understand the frustration with the unpaid balance owed to the hospital. To help resolve this issue for our customer, we contacted Ms. Gregg’s primary health insurer and verified that the entire Swiss hospital bill was 13324.35 Swiss Francs. This converted in their processing system to $10,362.09.
Now, the bottom line is what amount Ms. Gregg owes to the hospital. This would be the difference between the hospital bill of $10,362.09 and what we initially paid the hospital: $9,688.72. The difference is $673.37. As we are a secondary insurer in this claim, we were waiting for documentation from her primary insurer in order to determine what additional amount we may have owed.
We have expedited payment in the amount of $673.37.
Lesson learned? Always put your appeal in writing. Thomas called Access America to dispute the bill, and considering the complexity of his problem, he was turned down.
It’s a little-known fact that more than 90 percent of appeals to insurance companies go the way of customers. I think Thomas could have gotten his money back without my help — eventually.
(Photo: Problemkind/Flickr Creative Commons)
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{ 12 comments… read them below or add one }
All of which is yet another reason to spend about $200 a year to be a member of MedjetAssist. There are no maximums, no conditions, no asterisks, nothing. I broke my ankle at Machu Picchu in 2004 and after 36 hours at a hospital in Cusco, a MedjetAssist Lear Jet swooped in to rescue me. When we landed at LGA, the ambulance was on the tarmac, and the MedjetAssist nurses refused to leave me until they’d tucked my into my bed at Mount Sinai Hospital. I never saw a bill, an invoice, nor any correspondence at all. Traveling anywhere without a MedjetAssist card in your wallet is like driving your car and not being a member of AAA: sheer recklessness.
pay!:P
Actually Susie appears to be lucky. A lot of US insurance policies won’t pay out of country expenses. Yet another reason why Travel Insurance is a good thing to purchase!
@Geoffrey
According to Medjet Assist the only service the provide is evacuation. Since the helicopter was paid for by Access, Medjet Assist would have been useless to the OP. I suspect that you had good medical insurance as well
@John
Or of course you can just call you health insurance and see whether they cover you out of county or if there are limitations. Blue cross, at least in California, generally covers you wherever you are.
Every and I do mean every insurance policy is different both domestic, international, travel insurance all of them – plus there are companies that seem to be insurance companies and they are not. I think you will find that most US health insurance policies will cover your medical expenses outside the US to the same extent they would cover them in the US. What they won’t usually do is pay for the transportation costs to get home or to a provider in another company. The travel insurers generally assert that they are secondary to your primary insurer and so they subrogate their claims back to the primary. It is a lot of paperwork and as I said is very complicated because every policy is different. Throw in language and system differences and you have a prescription (no pun intended) for a mess. “Caveat Emptor”.
So glad you helped her handle this dispute; Carver every BLUECROSS and BLUE SHIELDplan is different; It depends on what your emplyer selects for you. and Babel why should she pay; Also AAAis way overpriced ; I get the same coverage from my auto insurance plan at 12.00 per year; hope this did not affect her credit rating.
You hope you never have to use it, but travel insurance is vital for everyone. Dont depend on employer insurance. There is no guarantee that will carry abroad.
Medicare is only valid in the U.S.
Also check to see if the country you’re going to has free healthcare. Fainted from exhaustion in London and didnt pay a cent for anything. Nice folks.
There was no mention of a travel agent in the article.who could have given valuable assistment is resolving this case by presenting the facts to Access America in a 3rd party way where there would not be any personal emotions. However, we have two many so called travel agents who are excellent order takers and have no sales ability to follow-up with the travel insurance companies to help move the claim to a satisficatory end.
I am looking at two plans from Travel Guard. The “Basic plan” has a $10,000 medical expenses with a $50.00 deductable. The Platinum Plan has a $50,000 medical expense plan with no deductable The basis plan has a $100,000 Emergency Evacution while the Platimum Plan has a $1,000,000 Emergency Evacation providion.. Given that the couple taking the vacation that would be considered riskier (ski vacation), choosing a policy that had better benefits would have been a far wiser fact considering the small difference in insurance premium cost compared to the cost of an European Ski Vacation.
I am still using Blue Cross/Blue Shield–and the policy my former employee has does cover medical costs outside of the US. However, it does not provide for transportation back to the US to recover at a hospital near my house, so I also subscribe to MedjetAssist.
Yes, I did call BC/BS to ensure what they covered before leaving the country. And that is a good idea as others have said–contact your insurance company (or HR person) to find out what is covered, then decide what to do about the uncovered parts (like medical flights home).
Re: The 1st Reply
The link Geoffrey Weill provides links to a page that shows he does PR and marketing for MedJetAssist.