Holiday Insurance Woes

[meditek]

I took out holiday insurance with Atlasdirect before going to Florida for 4 months where I am at present. Before taking out the Insurance, I asked what would be the procedure if I was taken ill. I was told that "If Medical costs are likely to exceed £500 you MUST call Emergency Assistance Team." for which they supplied a phone number and intimated that they would handle billing.

I was taken ill with renal colic and staggered into the local ER in great pain. I told them that I was insured and the number to ring but they refused saying they did not deal direct with Insurance companies. I was in no fit state to phone anyone. I was then hit with some pain relieving injection that rendered me gaga and given a scan which revealed a stone which they said I would probably pass. I had had probably around 15 minutes medical time when I was presented with a bill for $6350. Being heavily doped and not in control of my senses they finally let me go after forking out $2600.

I contacted the insurance company who put me onto a company in Canada (CMN Inc.) who handle these matters for them. They sounded efficient and caring but wanted me to sign and fax forms which I did though I didn't feel really up to it. Meanwhile, further bills appeared by post from the doctors involved as well as the hospital totalling another $1200. All the bills that I received said that I was responsible for payment. Now, after 3 weeks, I have received no money from the company.

I am now in a position where I am short of funds for the rest of our stay. I am totally disallusioned by the Insurance. I have had nothing in writing from them at all. Soothing words on the phone are meaningless. They will be paying for a psychiatrist next! So, be warned, travel insurance is fine until you need it!

[Bookworm]

Unfortunately, most places in the US will not deal with travel insurance companies and clients are expected to pay first and claim second. This isn't something the insurance company can do much about, they can only cover costs if the other side will accept to deal with them, and the USA are notorious for this. It's not just insurance either, in the US, they will ask for payment before treating you, don't blame your insurance for this, blame the US medical system.

 

All you can do is chase up the handlers for reimbursement ASAP.

[meditek]

Thanks for your info. I blame my insurance company for showing no sign of paying me to the extent that I will have to cut the holiday short!

[Bookworm]

Have you checked if your insurance has a cash advance clause? They don't like people using it, but ultimately it could maybe help? ;-)

[meditek]

Only thing I have here is this except from my email to them. I have informed them the costs have given me difficulties.

 

"Should you require medical assistance abroad and where the costs are not likely to exceed £500 you are meant to meet these costs if you can, if you cannot then please call the emergency assistance team as per Europ Assistance contract of Insurance, we trust this is the one you are talking about."

[meditek]

This gets worse. They have now accepted my claim but are insisting I return to the UK for treatment or they will cancel my insurance. It would seem that the CT scan showed a couple of conditions (diverticulosis and some arteriosclerosis - there is no treatment required for either) that would be seen on around 70% of men of my age and which are completely syptomless. The kidney stone is history because it has been and gone and there are no more. I am actually a retired doctor so know what I am talking about. It would seem that they are trying to cover themselves against possible complications from two symtomless findings. I would suspect that if you scanned all 70 year old policy holders more than half would be sent home on this basis!

[Bookworm]

LOL, nice try, but they can't actually cancel your insurance if you refuse.

 

What they are obviously scared of is that some of the "issues" flare up and you end up in hospital costing them another few thousands $...

 

The terms of the insurance are all built in the same manner, curtailment/medical repat has to be due to "medical necessity". If you are not requiring medical treatment for these conditions, then there is no medical necessity for you to return to the UK. For them to try and diminish cover for a problem you didn't know existed before you took the insurance is also unacceptable.

 

They're trying it on big time, don't stand for it.

[meditek]

It's gets worse still. Excerpt from latest email :-

 

"If this patient refuses to return as per your medical recommendations we will limit liability to the cost of his repatriation at the time when we would have been ready to bring him home."

[Bookworm]

Whose medical recommendation?

 

You can demand that they refer your case to the underwriters, arguing from your own medical knowledge that medical repat is NOT a necessity at this point and advise that if they force you to repat against your will, you will take it all the way to the Ombudsman.

 

It is very important that you know whose recommendation they're working from. If it is from the agent reading from a medical report, it is far less powerful than if it is from the examining doctor.

 

A word of caution: IF you were to have an episode related to either of those conditions, they would probably have very good cause to refuse and pay up as you would have then refused to repat against their advice, so you need to weigh the pros and cons.

 

Sadly, a lot of people travel to the US with PMH to get treatment for which they would have to queue for a long time in the UK and try to convince the insco that it was an acute/unknown issue, and the assistance companies are taught to watch out for the "treatment tourists". :-|

[meditek]

LOL, nice try, but they can't actually cancel your insurance if you refuse.

 

What they are obviously scared of is that some of the "issues" flare up and you end up in hospital costing them another few thousands $...

 

The terms of the insurance are all built in the same manner, curtailment/medical repat has to be due to "medical necessity". If you are not requiring medical treatment for these conditions, then there is no medical necessity for you to return to the UK. For them to try and diminish cover for a problem you didn't know existed before you took the insurance is also unacceptable.

 

They're trying it on big time, don't stand for it.

 

Thanks for that. Not standing for it is proving difficult because I cannot get past the juniors.

[meditek]

Whose medical recommendation?

 

You can demand that they refer your case to the underwriters, arguing from your own medical knowledge that medical repat is NOT a necessity at this point and advise that if they force you to repat against your will, you will take it all the way to the Ombudsman.

 

It is very important that you know whose recommendation they're working from. If it is from the agent reading from a medical report, it is far less powerful than if it is from the examining doctor.

 

A word of caution: IF you were to have an episode related to either of those conditions, they would probably have very good cause to refuse and pay up as you would have then refused to repat against their advice, so you need to weigh the pros and cons.

 

Sadly, a lot of people travel to the US with PMH to get treatment for which they would have to queue for a long time in the UK and try to convince the insco that it was an acute/unknown issue, and the assistance companies are taught to watch out for the "treatment tourists". :-|

 

Good question. Probably some nurse. I asked for a proper doctor to review it which I suspect they are doing now.

 

Your word of caution surprises me considering your earlier comments regarding unknown conditions. As I may have said the two conditions referred to require no treatment, would only be found by accident in the absence of trouble and would be found in probably the majority of 70 year olds subject to a CT scan!

[Bookworm]

Hence my advice to tell them in no uncertain term you want it referred to the underwriters.

 

The assistance company are the ones dealing with your case at the moment. They are contracted by the insco to handle all their cases, and the assistco will then bill the insco, and the assistco has a certain amount of latitude to deal with most cases. However, in cases where things are not clear-cut, they will refer to the underwriters for their decision and if you make enough noise, odds are that the u/writers will cave in especially if they are threatened with the Ombudsman, and the assistco will do what the u/writers say.

 

My advice is: Stress that as a doctor yourself, you know that you are not at risk from the findings in the scan, that you were not aware of this issues when you travelled and acted in good faith and expect them to do the same. Tell them that if they are willing to pay for it, you will gladly go back to a doctor for his professional opinion, but that you will not accept a judgment call made by either an agent in Canada or an assistance company in the UK who don't actually know what is going on and that you expect them to honour their contractual obligation with the same good faith with which you took the insurance.

 

(all this on the proviso that you are pretty sure that you are not at risk of an episode whilst there, as I said before, things could get nasty if you were to need hospitalisation for these medical reasons)

[meditek]

(all this on the proviso that you are pretty sure that you are not at risk of an episode whilst there, as I said before, things could get nasty if you were to need hospitalisation for these medical reasons)

 

Who can be sure of anything at 70? A stroke or heart attack could easily be blamed on something common at that age. As you said before, I didn't know about them before leaving and, as I said before, I have no symptoms and there is no effective treatment for either except exercise and a good diet. I play golf 3-4 x a week and consider myself pretty fit for my age so what would returning home do except to sit on my arse through the cold wet winter! So being forced home as a 'medical necessity' simply doesn't add up.

[Bookworm]

Ah, sorry. We're both typing at the same time, lol.

 

Ok, the thing is I can tell you exactly why they want you home: they're worried about differential diagnosis: Cancer of the colon, IBS, IBD or ischemic colitis. In the UK, that wouldn't be such an issue, but in the US, if you've got insurance, you also have some of the most advanced techniques for tx and the sky (or your insurance ceiling) is the limit. Currently, your insco are sitting there and seeing signs of $$$$ flashing in front of their eyes and they're prepared to swallow the cost of the repat + reimbursement of the rest of your wasted holiday because it STILL would cost them less than if you had to spend some time in a US hospital.

 

As for the arteriosclerosis, they're panicking at the idea of what can follow the hardening of the arteries... Again, they're looking at damage limitation in case your condition were to deteriorate.

 

As far as the insco is concerned, you MAY be a walking timebomb and so they'd rather have you back in the UK where it would cost them nothing for you to get treated.

 

As far as "good cause" is concerned, I wasn't very clear, I apologise. What I meant is that as far as THEY are concerned, they would have good cause to refuse to cover and you would then have a fight on your hands just to get them to cover what they should. Pathetic, I know, but that's insurance companies for you.

 

Bottom line (if you'll excuse the pun) is that your cover is adequate and that since you had no prior knowledge of these conditions and no reason to suspect them, they would have to cover you if something happened, as any consultation of your medical records would show. So they're trying to force your hand by saying "ah well, if you stay behind against our medical advice, you're voiding your policy". But I am not aware of any terms in the policy that says that. In order to return early at the client's request, they have to approve the medical necessity, but I can't say that I have ever seen insurance terms where they can force you to curtail just in case you get ill... That is after all what you took insurance for.

 

Hope that's a bit clearer.

[Bookworm]

And I agree with you about pre-existing conditions etc... but never underestimate to which limits an insco will be willing to stretch if it means a chance of them not paying out.

[meditek]

Thanks. Pretty clear.

 

But surely, the threat to only repay repat costs, if I don't return, and cop out of the medical costs so far is blackmail?

[Bookworm]

Welllllll, if you must use ugly words...

 

It would also be a breach of contract etc... but they rely on people being too scared of being left without cover in a country where the medical costs are astronomical.

 

Personally, I would write a stinking letter of complaint on return to the UK anyway, because this kind of behaviour is simply disgusting.

 

Sorry, I'm going to log off now (stinking headache), but if you have any more questions, ask away, I'll be back in the morning, you're what, GMT -5?, so nothing much else is likely to happen over the weekend.

 

Meanwhile, you could always do a bit of simple research to send them conclusively showing that both conditions are nothing for them to panic over and certainly no reason for them to try and repat you early.

 

Good night, try not to let them worry you unduly.

[meditek]

LOL, I have been very conservative with my language online. My wife tells me that I've been using words here at home that she never suspected I knew!

 

Last time (15 years ago) I became loquacious about holiday insurance was way back when my wife dropped her 13 month old Nikon Camera (Cost new £325) in the Indian Ocean and I received £48. At least with home insurance for burglary etc you get to come face to face with someone but this is like dealing with phantoms.

 

Forgot to say that one of my daughters is a solicitor. I spoke to her about it all but there were an awful lot of 'ifs' but she's into a different area and probably was as clueless as myself!

 

Am gradually coming round to the view that we are not likely to return here to the USA again. Leaving early will cost me around $15,000 as I paid for everything in advance. Some hints on how to extend the stay to the end of November would be a bonus. Surely, I would have to sign things - well maybe not!

[Bookworm]

As I said, if they insist on their knee-jerk reaction, then demand a referral to the underwriters. The assistco will do what the insurers tell them to, and if the insurers think they're going to end up with the Ombudsman on their back, they'll think twice. It is very odd that the Ombudsman which is so inefficient in other matters is very sharp when it comes to travel insurance misdeeds, and the industry does NOT like them very much.

 

Your insurance T&Cs are online, but there are different policies depending on when you took it, so you need to check which one applies to you.

 

Atlas Travel Insurance and Cheap Holiday Insurance for Annual Travel and backpackers and ski insurance

 

Once I know which one is yours, I can go through the small print and see if they have an escape clause or if as I suspect they are just trying it on, and advise you further. ;-)

 

You also need to make sure when you kick off that if they DO force you to repat, you will be claiming the $15000 loss off them since it is their decision which would cost you that. In the end their decision will be based on what's the least expensive for them.

 

I would suggest that next time, you go with a specialist insurance like SAGA who are more sympathetic to the older elements of the population.

[meditek]

Good morning Sir,

 

My policy is the ADX version.

 

There is a maximum £3000 on losses.

 

Incidently, if I did return home I would do so alone, leave my wife here and come back after 'treatment' though they have yet to tell me what treatment I require.

 

Anyway, I have found some insurance over here that will cover 'pre-existing' conditions. The only problem is that there is a clause about double insurance. I would want my wife to continue on the present insurance because it is not cheap.

 

My inclination is to raise two fingers to Atlas, demand that they pay up for expenses so far and remove me from the policy.

 

Incidently, I have asked them to refer the case to the Underwriter and mentioned the Ombudsman. Them = Europ-Assistance who are part of CMN in Canada. Atlas Customer Relations simply ignore my emails.

 

Also, I am supposed to see a Urologist on Tuesday simply to show him the stone and get the OK on the problem. They were going to pay for this but the threat to only pay repat expenses makes me very loath to see him as he could well add another few thousand to the bill but, if I don't, then they could claim I still require treatment for the stone. Clever.

Edited November 7, 2009 by meditek

[meditek]

Incidently, I have asked them to refer the case to the underwriter. Them = Europ-assistance who are part of CMN in Canada. I have had no contact so far with Atlas whose Customer Relations Dept simply ignore emails.

[Bookworm]

Good evening, Sir (and I am a "Madam", but don't let that worry you! )

 

Interesting... I have now gone through your policy docs with a fine tooth comb and I can see what they are using:

http://www.atlasdirect.net/holiday-insurance/help/PolicyWording2009F.pdf

SECTION 2 MEDICAL EMERGENCY & REPATRIATION

What is covered:

 

We

will pay You the following costs, up to a maximum of £10,000,000, per each

Insured Person

who suffers sudden and unforeseen bodily injury or illness, or who

dies during a

Trip outside the UK Area:

฀

Reasonable medical expenses for the immediate needs of an unforeseen

medical emergency. Included are

Medical Practitioner’s fees, hospital

expenses, in-patient and out-patient medical treatment and charges for medical

transportation to the nearest suitable hospital abroad, when deemed necessary

by a recognised

Medical Practitioner.

฀

Burial or cremation of a deceased Insured Person abroad up to a maximum

of £2,000; or alternatively transportation costs of returning

Home an Insured

Person

’s body or ashes.

฀

Additional travelling costs to repatriate You Home when recommended by

Our

Medical Officer. We will pay for the cost of a medical escort if considered

necessary.

We reserve the right to limit payment to what Our Medical Officer deems to

be reasonable.

If Our Medical Officer advises a date when it is feasible and practical to

repatriate You, but You choose instead to remain abroad, Our liability to pay

any further costs under this Section after that date will be limited to what

We would have paid if Your repatriation had taken place.

 

See what I have stressed in red. According to this, it would appear they're in the right, right?

Well, no. This scenario is for cases when people have missed their return flights due to medical problems and therefore need to be repatriated. In some cases (usually the fakers, it has to be said), people will say they are not well enough to be repatted yet, hoping for the insurance to pick up the tab for a couple of weeks more in the sunshine. THAT's when the above terms apply.

In the end, it will boil down to the interpretation of the policy wording and any company to consumer contract in the UK is covered by the UTCCR, in which it is set that if terms are found to be ambiguous then the interpretation most favourable to the customer will prevail.

Beware of returning home, as at that point when you go back to the US, your condition will have become pre-existing and needing to be declared at which point they will either decline to take you on or hike your premium.

There is no need for this: You took insurance to cover you in case of medical emergency in good faith and disclosed all PMH. You then had a medical emergency, as per yout insurance terms and have donme everything you were supposed to, and they charged according to the information disclosed and known to you at the time. Now they're not happy because you might end up costing them more than they expected, they want to move the goalposts.

Personally, I wouldn't move an inch and warn them that if they try to unilaterally alter the terms of your cover, the next communication they'll get is from your solicitor and you reserve the right to sue them for breach of contract if they don't honour those terms, as well as make the strongest complaint to the Ombudsman.

I have heard a few ludicrous things in my time, but this one takes the biscuit.

Edit: I just double-checked and it would seem Europ Assistance are the underwriters of all Atlas policies as well as providing the assistance company (which is fairly logical that they should sub-contract to a subsidiary, but I digress).

00 44 1444 411 999 is the switchboard number for EA in Haywards Heath, if you can call there and make sure you're put through to "Quality Dept", which is complaints and make your voice heard loud and clear, the more fuss you make, the more they're likely to move their backsides. ;-)

[meditek]

I cannnot thank you enough for you help (Madam ).

 

With regard to your interpretation in red where does it say this is meant to apply to a missed flight? Can I claim for the $15000 as I did not cancel? Can I claim for bringing in 200KG excess baggage that we have accumulated here over the past 10 years?

 

The past 3 weeks of our stay has been ruined by their inaction, lying awake at night wondering what they will do next etc. Frankly, I am almost at the point of packing in!

 

Edit :- A few years ago I came across some holiday 'insurance' that stated that it would not pay if you had previous history of a number of things, one of which was 'anxiety'. Now, as a Doctor when patients came with 'stress' syptoms I often used to write 'anxiety' in the notes and never used to word to them because many got annoyed! I suggested to the Insurance Company that this clause could possibly rule out about 80% of claims as many people would not realise they were not covered. They weren't interested so I asked the BIA what they thought of it. The BIA replied that companies were entitled to make any terms they liked which makes me even more nervous over the item in red!

Edited November 8, 2009 by meditek
Extra

[meditek]

I would really appreciate clarification of your conclusion about the Red lettering.

 

Meanwhile, to bring you up to date, they have agreed to pay for a visit to a Urologist tomorrow. Hopefully, he will confirm that the problem is gone so that they will have a difficult job justifying returning home.

[Bookworm]

Sorry, haven't been around much (autistic teenager kicking off at home).

 

With regard to your interpretation in red where does it say this is meant to apply to a missed flight?

It doesn't. But that's the accepted benchmark within the industry. If you want to break it down in words (and again this is fairly subjective), if you have to return before your original date, it's "curtailment", if you miss your flight due to illness and have to come back late, it comes under "repat".

 

There are exceptions, of course, nothing is set in stone. If you were found to have highly advanced cancer in the US for example, and the longer you stay abroad, the sicker you'll get with no chance of remission, the insco would then be likely to pay whatever it takes to get you home early because of the medical costs invoved. On the other hand, the same medical scenario wouldn't necessarily create the same sense of urgency if if happened say in France, where medical bills are covered under the EHIC agreement.

It's swings and roundabouts, but the 2 over-riding elements are cost effectiveness and medical necessity. So your argument must be: Is it medically necessary for you to return home? and if not, then what is their criteria for wanting you to repat early? The fact that you might get sick again is ridiculous. Anyone who goes anywhere might get sick. Hey, that's why they take out insurance!

Can I claim for the $15000 as I did not cancel?

If they force a repat without a VERY good reason, I would, as their breach of contract is what causing you this very substantial loss. Do talk to your daughter about it though, I'm sure she can confirm or deny. Tell her not to look at it from an insurance angle, but from a breach of contract angle and she should see what I mean and advise you more efficiently.

Can I claim for bringing in 200KG excess baggage that we have accumulated here over the past 10 years?

I don't see how that's relevant, or is there a gap in your story somewhere? Sorry, I am confused here. :-?

The BIA replied that companies were entitled to make any terms they liked which makes me even more nervous over the item in red!

Well, the BIA would say that, wouldn't they? But no, they can't. Their terms in fact, like any other contractual terms, have to comply with quite a few regulations, the UTCCR in particular. Terms which would allow them to vary your cover at will to suit them and diminish their liability would definitely be an unfair term, and just to be clear, a term which is deemed unfair under the UTCCR is non-enforceable in its entirety.

 

It's like you asking a man to change your roof tiles and he quotes you for that, and you agree on those terms. 1/2 through the job, he realises that it is going to cost a lot more than the fixed agreement and says: "Well, I can't do the whole thing in tiles, so I'll used what I have and then finish the rest with felt and tar". He is trying to unilaterally alter the terms in a way which is of no benefit to you, the balance of power is with him.

 

That's what the insurance are trying to do with you. They agreed to cover you for medical emergency care, up to a ceiling of [policy limits] for [x amount of time until planned return] and calculated the premium based on those 2 factors + [risk factor involved, taking in consideration age, PMH, destination etc...]

 

Now they have found out that you may cost them more should you stay and they are, so to speak, switching to tar and felt or threatening to leave the roof only 1/2 done.

 

The fact that you are an ex-GP should be sufficient in itself to give you very good grounds to argue. Where most people wouldn't know what diverticulitis or a/sclerosis involve, you do. You are truly the best person in this case to argue with them. If you manage to speak to them, you might see if you can get through to one of the doctors on the team and discuss things with him directly, come to think of it.

 

Where I used to work, I know that a case like yours, yes they would have tried to bring you home early as the lazy and safe option. But I also know that faced with someone who knew his medical onions and could argue the lack of medical necessity, the medical team/underwriters would give in quite easily as they knew they were on dicey ground.

 

Let us know what the urologist says, hope you're aok.