Look for the preexisting-condition clause when buying travel insurance

By Wayne Wirtanen
This item appears on page 46 of the May 1995 issue.

Editor’s note: Having written sev­eral articles on travel insurance for ITN (April ’94, pg. 34; July ’94, pg. 51; Aug. ’94, pg. 37, & Oct. ’94, pg. 30), Mr. Wirtanen expressed inter­est in commenting on the issue dealt with in the letter by ITN reader Mr. Brewer, appearing on the preceding page. Herewith are the results of his research.

In ITN reader Mr. Brewer’s letter (page 45), his most important com­ment, in my opinion, is this: “It appears that the terms of TEN’s coverage are now quite similar to those of other insurers. Too bad.”

My sentiments exactly.

The lack of the preexisting-condi­tion clause was one of the unique aspects of TEN’s coverage when I
highly recommended it last year. (The other unique advantage is still the very attractive price: a whole year’s coverage is $30 for an indi­vidual or $50 for an entire family.)

If you are a policy holder who has need of TEN’s emergency services due to an illness, there now will be the usual hassle of supplying TEN with your doctor’s statements and your medical records in order for YOU to prove that some preexisting health condition does not prevent payment.

TEN has made other changes in coverage since last year, adding some provisions but also adding a cap of $45,000 to aggregate cover­age, when coverage of evacuation costs had been unlimited.

Although very rare, the cost of emergency evacuation, accompa­nied by a doctor, from some parts of the world can amount to a ruinous amount of money for many travel­ers.

In cases of impending expensive medical evacuation, the insurance company will attempt to contact your doctor for medical information that will demonstrate that your medical history will or will not al­low the insurance company to au­thorize the expense.

The insurance company usually will have a few days to accomplish this while the patient is “stabiliz­ing” in the nearest medical facility.

In the exceedingly rare case in which time does not allow full re­view of your medical history, a spokesperson from American Ex­press Travel Insurance told me that the evacuation, at least to the clos­est appropriate medical facility, would be made without delay and probably at the insurance company’s expense.

TEN, if requested, will review your medical records before a trip and advise whether or not an emergency related to this or that preexisting condition will prevent their provid­ing the services outlined in their policy.

With any travel-insurance policy, claims of any kind for accidents do not have this built-in preexisting condition problem, of course. Ill­ness. however, is the major cause of trip cancellation or overseas health- insurance claims.

That all-important travel- insurance paragraph

Since a large fraction of ITN’s readers are no longer “spring chick­ens,” and we’re likely to have some darn health “condition,” let me re­view the “preexisting-condition” is­sue.

(Also, you can refer to my article “Overseas Travel Insurance—Mag­nifying the Fine Print” [April ’94, pg. 34], It identifies which travel- insurance companies are the most

lenient in consideration of preexist­ing-condition claims. If necessary, send me a business-size SASE for a reprint of the article.)

EVERY travel health or trip-can­cellation insurance policy has this preexisting-condition disclaimer of coverage in one form or another.

Basically, they won’t pay if they determine that you had a health condition during some period prior to the effective date of the policy and that it was responsible for the subsequent claim.

It’s reasonable of the insurance companies to not want the risk of insuring someone who really isn’t healthy enough to be traveling or whose health is clearly deteriorat­ing.

Access America’s (800/284-8300) text describing terms and condi­tions is fairly typical of an insur­ance company’s position, as follows:

“The program does not cover losses or expenses if they result from any illness occurring during the 60 days prior to and including the effective date of 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.

“However, if the condition is con­trolled (not exhibiting symptoms or requiring the adjustment of treat­ment or medication) throughout the 60-day period through the taking of prescription drugs or medications and travel restrictions are not ad­vised by a licensed physician, then the medical condition is covered.”

The insurance company’s leaflet/brochure will have their preexisting-condition fine print somewhere in the text. Don’t wait until you have to file a claim to read and understand ALL of the fine print. The policy is a legal contract.

If you read this (relatively toler­ant language), or your policy’s para­graphs, carefully, it would seem to be complex, but it is understand­able. Ask your travel agent for ad­vice and/or clarification.

(Compare before you buy; some policies do not cover problems re­lated to preexisting conditions un­der any circumstances. And some policies have periods of up to 180 days prior to the effective date of the policy during which the condition has to be “controlled,” by their defi­nition, in order to be covered.)

The insurance company’s leaflet/ brochure will have their preexist­ing-condition fine print somewhere in the text.

Don’t wait until you have to file a claim to read and understand ALL of the fine print. The policy is a legal contract.

In any case, if you file a health/ illness-related claim of any kind, a travel-insurance company will not pay until medical records/health history will let them decide whether or not the terms and conditions of their policy have been met.

Cases in point

The following is an example of a potential problem with a claim.

• The Jacob Krumbeins of Pensa­cola, FL, paid $500 for trip-cancel­lation insurance to cover their $14,000 cruise package. When a medical problem last July caused cancellation, the cruise company refunded $12,500 and Krumbein filed a $1,500 claim with Travel Guard (800/782-5151).

The claim is still pending; the initially supplied doctor’s letters have not been adequate to convince Travel Guard that the claim should be paid.

ITN sent Travel Guard a copy of Krumbein’s letter to ITN that out­lined his frustration in resolving this claim.

Travel Guard sent ITN the fol­lowing response:

“We are responding to your in­quiry concerning the trip cancella­tion claim for Jacob and Ruth Krumbein. This case is pending, based on the receipt of (their doctor’s) recorded office notes from the Oct. 13, 1994, visit. We have requested this information on Oct. 17 and again on Nov. 7, 1994.

“We did receive a letter from (their doctor) dated Oct. 13, 1994, with general information concerning Mrs. Krumbein’s medical condition. This same letter also states the doc­tor ‘would like to see Mrs. Krumbein in one year,’ which does not seem to support a serious medical condi­tion. Obviously, if it was necessary on Oct. 13, 1994, to cancel the trip departing Nov. 11, 1994, we are looking for this medical proof.

“It is not unusual or unreasonable for a request of actual office records to support an illness. The policy lists the definition of sickness as ‘an illness that is so disabling as to reasonably cause a trip to be can­celed.’

“The Krumbeins entered into a contract of insurance that requires proof of loss, and we are exercising our right to clearly see the facts of the case.

“Upon receipt of the requested information we will review the case for a final decision.”

Krumbein says that he has com­plied with Travel Guard’s requests for further medical documentation from the busy doctors at Mayo Clinic, but he is ready to throw up his hands and consider that the aggra­vation of all this makes the claim not worth pursuing.

I would offer the following advice.

It’s up to you, the policy holder, to prove the right to your claim per the terms of the policy/contract. Persist in responding to the insurance company’s requests; they’ll keep the file open until there is some final decision on their part.

Keep copies of all correspondence, including letters that you have sent. If you are finally not satisfied, you can appeal to your state’s Depart­ment of Insurance, Claim Services Bureau.

In California, the Department of Insurance does not, however, func­tion as a “court of last resort.”

A spokesman told me that the Claim Services Bureau’s function is primarily to determine that the in­surance company’s decision is “ten­able” (which my dictionary defines as “capable of being held, main­tained, or defended”) and that the insurance company has followed its procedures properly — not neces­sarily that the insurance company’s decision is unchallengeable.

If worst comes to worst, I was told that the only practical final recourse is through a small-claims court, as the cost of other litigation would probably be prohibitive.

(In California Small Claims Court, the upper limit for claims is $5,000 — and you’ll need all of that saved correspondence plus the medical records, etc., that would prove your case.)

Here is another example of a po­tential claims problem.

• James Huber of Bakersfield, CA, had an unsatisfactory experi­ence with the medical-record-review procedure, in connection with a pre­existing-condition-related trip-can­cellation claim with Access America.

Access America has reviewed the provided medical records and Huber’s doctor’s statement, which said, regarding ongoing medical monitoring results, (I) “consider this stable. . . for those months men­tioned. Clinically, he was also doing quite well at that time.”

Huber’s doctor’s statement contin­ued: “I feel that with this background, with his. . . (condition). . . being status quo three months prior to his planned departure and then . . .(a change in condition after purchase of the policy). . . necessitating sur­gery and cancellation of his trip, a refund of his money should be done.”

Access America has denied his claim based on their determination from medical records that the pre­existing condition was not stable or “controlled.”

The lesson? Your doctor’s state­ment alone may not be adequate to assure payment of a claim.

In summary

First of all, use your head when considering travel, if you are not reasonably confident of your health. If family members are trying to talk you out of the trip, don’t ignore their advice.

Buy travel insurance with your eyes open. Understand exactly what coverage you are and are not getting for your money.

I bought a policy from TEN and still feel that their coverage is a good value for a traveler, even with the new conditions, as long as the purchaser has health coverage that covers actual medical costs that are incurred overseas.

I don’t know of any “regular” health-insurance policy that will pay for major overseas medical-evacua­tion costs.

TEN’s coverage does not pay the costs of actual medical expenses overseas (they will advance money, in some cases, which must be re­paid); they do provide a number of useful services, including arrang­ing for, and paying for, medically required evacuation.

Pleased policy holders

Check the October ’94 Boarding Pass column (page 4) for reader Adele Trobe’s glowing report of TEN’s service when she fell and broke both ankles in Corfu, Greece.

Briefly quoted, Adele said, “They got in touch with the hospital, the doctor, Philadelphia and the air­lines (those for which we had tick­ets to leave the next day and those willing to bring home a fracture patient on a stretcher — Delta wasn’t; TWA was). TEN even had the driver called who was to meet us on our return to Philadelphia.

“In a few days ... (a) doctor arrived to take over and escort me personally all the way home to Bryn Mawr Hospital, which they had pre­pared for my arrival. (They told us my husband was too old to act as escort.)

“I traveled via three ambulances, two planes and ‘medical storage’ in
the Athens airport waiting for my New York flight. In all, with changes, it took 24 hours, but I slept (with medication provided by the doctor) a good bit.”

“So, thank you for telling us (about TEN), ITN. You were a lifesaver.”

In the research trips for our col­umn in ITN, Adventure Travel for the Mildly Adventuresome, Saima and I tread some “paths less trav­eled” where medical treatment is nowhere near U.S. standards.

(Medical care for serious problems in the increasingly popular tourist areas of Eastern Europe, China, Mongolia and the former Soviet Union leaves much to be desired.)

No “spring chickens” ourselves, TEN’s coverage gives us some confi­dence that we would, if necessary, be hauled away from those less- traveled paths to adequate medical treatment.