Insurance claim denied

By | May 22nd, 2007

Q: I recently booked a vacation trip to Cabo San Lucas, Mexico. Since I was visiting during hurricane season, I also bought travel insurance through Access America.

Five days before buying my trip, I had my annual physical exam. After booking my vacation, my doctor phoned me and asked me to come back for a consultation. I was diagnosed with prostate cancer, and several weeks later, my doctor advised me to cancel my vacation.

I submitted a claim to my travel insurance company. It was denied on the grounds that I exhibited symptoms on my visit to my doctor before booking my vacation.

I told the insurer that I had medical records that indicate I had no knowledge of a possible illness when I visited my doctor. The insurer and its consumer advocate say that I don’t have to have knowledge of the symptom — the policy requires only that I have a symptom.

What a rip-off! Can you do anything for me? I could really use the $900 for my mounting medical bills.

— Al Cooper, Albertville, Minn.

A: I’m sorry to hear about your illness. Access America’s denial of your claim is obviously not making this any easier for you.

Unfortunately, every major travel insurance company has a clause that lets it off the hook for a pre-existing medical condition. The question is: Does your medical history fit Access America’s definition of a pre-existing condition, or not?

According to Access America, a pre-existing condition is defined as “any injury occurring prior to and including the effective date” of your policy and “any illness occurring during the 120 days prior to and including the effective date of this insurance for which treatment by a licensed physician has been sought or advised or for which symptoms exist which would cause a prudent person to seek diagnosis, care or treatment.”

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In other words, if you thought you needed to see a doctor because of symptoms that ended up being a sign of serious illness, then that would be considered a pre-existing condition. But your doctor’s visit was a routine medical exam. There were no symptoms of cancer.

Here’s what apparently tripped up your insurance company: Your initial tests, conducted several days before you booked your vacation, showed elevated levels of protein in your blood, which can be a sign of prostate cancer. But you weren’t notified of the test results until after you booked your Mexico vacation.

In my experience, travel insurance companies very rarely overturn their decisions (even when I get involved). But this seemed to be a case where Access America didn’t have all the information about the timeline of your illness.

When you are filing a claim on your travel insurance, it’s important to first look at your policy to see what is (and isn’t) covered and to offer the records that will allow the company to honor your claim. In your case, Access America simply needed more facts.

I contacted the insurance company on your behalf. A representative called you, and you were able to give him the information he needed in order to honor your claim.

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