how to appeal a denied claim for travel health insurance

November 7, 2006 9:36 AM

My friend hurt himself and ended up with a six-digit hospital bill. The health insurer has denied his claim because he had a couple of drinks that night. What are his options and best strategies for appeal?

We reside in Vancouver, BC. He was visiting a friend in Denver, CO during the summer, and felt queasy due to the altitude immediately upon arriving. That evening, he went to the bar with friends, and had two drinks. He definitely did not have more than two drinks. Some time later in the evening (still at the bar), he had a spell of dizziness, then very suddenly fainted. When he came to, he was in the hospital, and later had to be treated for a fractured skull and brain haemorrage. No-one knows exactly what happened – most likely he cracked his head on a barstool or on the floor.

At this point, he is physically fine. However the travel insurance carrier has denied his claim for the hospital bills, due to the issue of alcohol consumption. When he originally bought the travel insurance, he had asked about the escape clause about alcohol, and the insurance broker said something to the effect that it’s fine if you have a drink or two – your claim will be denied only if you go overboard. What we're being told now is quite different!

Are we SOL? What is the best way for my friend to appeal the claim and get the insurer to foot the bill?

posted by randomstriker to Work & Money (26 answers total)

Quoting the relevant part of the policy here would be most helpful.
posted by grouse at 9:44 AM on November 7, 2006

The best way to appeal the claim is to appeal the claim. Duh? Contact the insurer and ask how to appeal a claim denial. Then do it. You won't be able to get any relief in court unless you've exhausted the insurer's administrative appeals process anyway.

Then after that paperwork is in, go ahead and start researching lawyers. A six-digit claim is clearly worth legal assistance. You don't mention whether it's a Canadian or U.S. insurer, but whichever it is, find a lawyer who specializes in denied insurance claims (yes, it's a real specialty), and have a talk.

Get copies of all records! Contact the hospital, the local police, the bar, the ambulance service that picked up your friend, everyone! Build a case!

I would guess that the insurance company is reflexively denying this because the amount is so large and passing out at a bar could be deemed to be your friend's fault. Hopefully, there's a blood-alcohol report from the hospital that shows a low blood alcohol level.

Here's the wording from one travel medical policy: "[the policy doesn't pay for...] your chronic use or abuse (prior to or during your trip) of medication, drug or alcohol or deliberate noncompliance with prescribed medical therapy or treatment". If the wording is similar in your policy, I would very much doubt that normal alcohol consumption should be described as chronic use or abuse of alcohol. But the insurance company, facing a six-figure payout, has no good reason to make it easy for you.
posted by jellicle at 10:08 AM on November 7, 2006

Response by poster: The relevant exclusionary clause:

The Company will not provide coverage, provide services, or pay claims for expenses incurred directly or indirectly as a result of...

etc.

...the consumption or abuse of any alcohol, drugs or medication, or any event, act or omission caused or contributed to by any consumption or abuse of alcohol, drugs or medication.

etc.
posted by randomstriker at 10:34 AM on November 7, 2006

IANAL, but it sounds like the exclusionary clause denies coverage as a result of drinking *ANY* alcohol, not just excessive consumption.

I'd still attempt to appeal it, providing the documentation that jellicle cites.
posted by parilous at 10:55 AM on November 7, 2006

This is not legal advice.

What you have here is a problem where your contract language does not match what your seller told you. This is a huge area of legal dispute (look up "parol evidence rule") but I'll sum it up as "those that rely on oral assurances against written contract language usually wind up screwed."
posted by norm at 10:59 AM on November 7, 2006

Considering that it says "any consumption" i would think you're SOL, but I'm only a law student who will probably get a bad grade in contracts.
posted by wuzandfuzz at 10:59 AM on November 7, 2006

Perhaps I am showing my ignorance, but I'll ask anyways: Does the Canadian National Health Care Plan not cover its members while they travel to the US?
posted by mmascolino at 10:59 AM on November 7, 2006

So your friend owes a hundred grand in medical bills. He lives in a different country. What's the hospital going to do about it? Sue? How could they possibly collect? It's not like they can garnishee his wages or put a lien on his house.

Sounds like your friend's broker sold insurance fraudulently. Your case would, I suspect, hinge on what your friend was told by the broker. A good insurance lawyer will be able to find out if other people have had the same problem with that broker.
posted by solid-one-love at 11:03 AM on November 7, 2006

Does the Canadian National Health Care Plan not cover its members while they travel to the US?

It does not. US health care providers will not, for some reason, honour my CareCard. Go figure.
posted by solid-one-love at 11:04 AM on November 7, 2006

Actually, there's no "Canadian National Health Care Plan" - each province has its own.

To the original poster: has your friend checked with BC's Medical Services Plan? Here's what they say about reimbursement for care outside BC (here's their Out of Country Claim Form [PDF]).
posted by hangashore at 11:10 AM on November 7, 2006

The clause seems to say "as a result of..." the consumption of alcohol. Even if he passed out at about the same time he was drinkng, that doesn't mean that the medical problem was the (direct or indirect) result of the alcohol. So, though I'm not a lawyer, I'd say that wording, anyway, doesn't necessarily rule out coverage.
posted by amtho at 11:19 AM on November 7, 2006

Note that insurance agents customarily have Errors and Omissions coverage; if reliance on an assertion of the agent left you high and dry, you may have cause for action against the agent and his E&O carrier.

Get a lawyer, because I'm not one.
posted by baylink at 11:24 AM on November 7, 2006

Your insurer probably denied the claim on grounds that the consumption of alcohol contributed to your friends condition. Correct me if I'm wrong, but in court, they'll have to convince the judge that the drinking was the most plausible cause. Find a doctor who can attest that some other medical condition, like altitude sickness, was the major cause. Appeal the claim, with your doctors letter, then follow jellicle's advice. IANAL.
posted by Psychnic at 11:43 AM on November 7, 2006

Thanks for the info Hangashore...The media here in the states does talk about the Canadian system as monolithic so your info was news to me.
posted by mmascolino at 11:44 AM on November 7, 2006

Psychnic and I are thinking along the same lines. I seriously wonder if a mild case of altitude sickness was the actual cause of your friend's black out. Vancouver has an altitude of sea level to 167 m. Denver sits at 1,609 meters.
posted by onhazier at 11:52 AM on November 7, 2006

Some thoughts:
1) Alcohol exacerbates altitude sickness--Easy to Google
2) The language says directly or indirectly cause
3) I would guess that it will be extremely difficult to vacate the language of the contract
4) I have no idea how one enforces international collection of bad debts but I would imagine there is a procedure.
5) Seek the advice of counsel and be prepared to negotiate a modest settlement.
6) Travel Insurance is usually written in very plain language, is full of exceptions which are usually quite clear and is very reasonably priced.
Technically, this is a very difficult question. Good Luck
posted by rmhsinc at 12:03 PM on November 7, 2006

Does he have health insurance otherwise?
posted by electroboy at 12:40 PM on November 7, 2006

It does not. US health care providers will not, for some reason, honour my CareCard. Go figure.

Holy shit! I didn't know that! I had always been under the impression that MSP would pay for hospitalization or, if the treatment was to be ongoing, for the flight home.
posted by Turtles all the way down at 1:14 PM on November 7, 2006

mmascolino writes "Does the Canadian National Health Care Plan not cover its members while they travel to the US?"

In BC and Alberta (and I'd guess all other provinces) Healthcare will only pay for things that it would cover at home and to the amount it would pay at home.

Because of differences in the systems this means that a) they may only reimburse you for a fraction of US bill (medical services are cheaper in Canada) and b) they will only cover tests and procedures that would have been covered at home (American hospitals tend to order more and costlier tests because of the higher malpractice costs). EG: an ambulance ride here is C$284, it was well over a grand in Oklahoma City when I was there eight years ago.
posted by Mitheral at 2:58 PM on November 7, 2006

Holy shit! I didn't know that! I had always been under the impression that MSP would pay for hospitalization or, if the treatment was to be ongoing, for the flight home.

It was my understanding that BC MSP only covers transportation in extreme circumstances, such as being stranded in the Northern Interior and needing an emergency airlift to Prince George, but that there were no cases where international transportation would be covered. As another poster wrote, my earlier statement wasn't completely correct, but the amount that one can get paid out is so small that it is nearly irrelevant. The OP's friend might get $750.

EG: an ambulance ride here is C$284, it was well over a grand in Oklahoma City when I was there eight years ago.

And ambulance costs aren't even covered by the BC Medical Services Plan. That's why, when I broke my leg earlier in the year and I wasn't certain that ambulance rides were covered by my employer's extended medical plan (they are), I called a cab to drop me off at emergency.
posted by solid-one-love at 3:11 PM on November 7, 2006

So your friend owes a hundred grand in medical bills. He lives in a different country. What's the hospital going to do about it? Sue? How could they possibly collect? It's not like they can garnishee his wages or put a lien on his house.

I have no idea of the legal basis, but I know that UK citizens who incur medical bills in the US get pursued by "International debt recovery agencies" who, if nothing else, can annhilate your credit record. I think they might have access to nastier powers as well.
posted by Luddite at 3:50 PM on November 7, 2006

(not legal advice. This is just information)

From what I remember from law school, the courts have found that there is an implied term in ALL insurance contracts that both parties will act in good faith. This means not misleading the other party, and not using minor technical excuses or wording like that(any alcohol whatsoever makes someone inelligible) to screw someone over.

I would definitly check with a lawyer on this, or go for a free consultation. Make sure to take proper steps and best of luck in getting recovery.
posted by newatom at 4:04 PM on November 7, 2006

PS: By "courts" I am referring to the Supreme Court of Canada, so it would apply to the contract made in BC.
posted by newatom at 4:07 PM on November 7, 2006

The poster above who suggested that a Colorado creditor couldn't sue a Canadian debtor for non-payment couldn't be more wrong. While the hospital would probably have to sue in the debtor's local Canadian court, such lawsuits by American creditors in Canadian courts against Canadian debtors happen every day. If the creditor wins they are entitled to every recourse for enforcement that a Canadian creditor would have. (Garnishment might be among those recourses, I don't know.)

I am not your BC lawyer, etc., but it strikes me that the eventual right play, is some kind of judo. When the hospital sends a nastygram call them up and say, "Look, I can't pay, not in a hundred years. No blood from a stone, etc. But look at the insurance company and the agent I bought my insurance from. They can sure pay. Let's team up..."
posted by MattD at 4:28 PM on November 7, 2006

The poster above who suggested that a Colorado creditor couldn't sue a Canadian debtor for non-payment couldn't be more wrong.

Didn't imply that as a generality. Was speaking specifically to suing for medical expenses. I would be interested to hear of such a case -- where an American healthcare provider sued a Canadian in a provincial court, won, and was able to get any money. I have a buddy in a sheriff's office who says that he has never seen such an order.

And just blue-skying here, but how can one be expected to pay for a service that one did not ask for? The OP's friend was unconscious, after all. He didn't agree to treatment, and with a head injury may not have been competent to agree to treatment after waking up. While Colorado law may find that irrelevant and require the patient to pay up, I would be very surprised if a Canadian court would agree that an unconscious person can enter into a contract.
posted by solid-one-love at 4:40 PM on November 7, 2006 [1 favorite]

solid-one-love writes "And ambulance costs aren't even covered by the BC Medical Services Plan."

In BC an ambulance ride is only $54 in most cases.
posted by Mitheral at 7:03 AM on November 8, 2006