What If Your Claim Is Denied?
Claims denials are rare, but when they happen they can be devastating. When you sign into a hospital in a foreign country, even though you do have insurance, you ultimately remain responsible for payment for services. If your insurer fails to pay up, you are still on the hook. We have already discussed that hospitals in the United States are not going to hold you hostage, we can’t say that for all countries, but they will not hesitate to demand payment after you leave or even send collectors after you. The fact you may reside in another country does not protect you.
But if contacted by a hospital with a demand for payment because your insurer refused to pay, don’t pull your cheque book out too quickly. American hospitals are used to waiting for payment. First of all, investigate the matter with your insurer. In my experience in reviewing ombudsman cases for Canadians for over a decade, at least three quarters of denials are the fault of the client—not understanding the terms, not disclosing requested information, shading the truth to get a cheaper premium, not notifying the assistance company as required, failing to follow the recommendations of the medical personnel, and so on.
But not all denials are justified, and just because yours might have been is no reason to take it lying in down and give in to the collectors. Assert your rights. Request a complete, detailed explanation of the reasons for denial from your insurer. A simple statement that your claim is denied because you failed to comply with certain reporting requirements is not good enough. Get the insurer or the assistance company to clearly define the points of your denial. Weigh them seriously, objectively and honestly within the context of your policy. You may think a denial is unfair, insensitive, inconsiderate or lacking in human compassion, etc. But what counts are the terms of the policy. Were the reasons for your denial consistent with the terms of your policy. If you feel they were not, don’t go running off to a lawyer just yet. Insurers can get it wrong too. Every insurance company has an appeal process. Request an appeal and present your case clearly using any documentation you think is relevant. Don’t play lawyer. Don’t make threats about going to court, etc., insurance companies are used to that. It doesn’t frighten them.
Gather your documentation, the policy in question, any additional medical data your doctor might provide, and set your case in plain language, with common sense. Make sure your insurer knows your side of the story. Make sure they know all of the facts. Sometimes, they don’t, and that can change their decision.
If the denial is still upheld and you honestly think you have been wronged, ask for a company ombudsman to review your dispute. Some insurers retain independent ombudsman to review dispute cases. Some are better than others. They don’t have legal status in that they can’t impose settlements, but they carry considerable weight and have often led insurers to reverse their denials. If you still feel your case has not been fairly assessed, according to the terms of the policy, appeal to your provincial ombudsman or financial affairs department, or to the Canadian Life and Health Insurance Ombudsman organization—a national, non-governmental body set up by the financial industry to resolve consumer disputes such as yours. This is voluntary organization. It is not an arbitrator. But its decisions do have considerable weight and insurers do pay heed.
After that you still have the courts. But that should be the last resort, not the first.
Hi my husbands claim has been denied, I am sending in an appeal, as we feel they are definately in the wrong for denial. We are being harrassed by the Hospital & Ambulance Co. ($82,000) Can they do anything to us in Canada like going into our Bank Accounts or Property also can they do anything in the USA also, I would like your info. on this if possible please.
Thanking you
Sheila
Sheila:
I assume you have appealed to your insurer. There are also other appeal sources available to you such as the Ombudsman for Life and Health Insurance (OLHI) which you can find on the internet. But they will look at your case only after you have gone through the appeal process with your insurer. You should tell the hospital and ambulance company that your case is under appeal: that may buy you some time. Yes, the collectors can seek restitution in Canada, usually by hiring a Canadian collection company, but they would require a court order before they could get into your bank accounts etc. If you don’t have property or assets in the U.S. there isn’t much they can do to you there. They certainly cannot stop you from entering the U.S.
Milan