Claims Appeal for a Kidney Stone - Acute Onset of a Pre-existing Condition in Visitors Insurance

Health insurance can be confusing and misunderstood—especially when it comes to the claims process, which can appear to be quite complex. It is important to understand that claims are paid based on the policy’s certificate wording. Oftentimes, a customer will try to appeal a claim on their own without fully understanding what they need to do only to have the appeal denied. This is when Insubuy’s Claims Resolution Specialists become extremely valuable: We can help you get your eligible claims paid.

There is no fee or charge for our Claims Resolution assistance. It is simply another one of our value-added services and one more reason to choose Insubuy for all your travel insurance needs. Here is an example of a claim we got paid.

Reason for Claim Appeal

A month before purchasing an international visitors insurance plan, the customer was treated for a urinary tract infection (UTI) in their home country. During the diagnosis of the UTI, they received a CT scan. The UTI was treated and no longer an issue before they traveled.

The customer purchased the international visitors insurance plan about a month after they were treated for a UTI in their home country. A few days after purchasing coverage, the plan became effective, and several days after the effective date, they sought medical treatment for pain they were experiencing. The doctor diagnosed the issue as a very small kidney stone.

The claims department denied the claim as a pre-existing condition, stating that it takes longer than 7 days for a kidney stone to develop.

Attempts to Appeal Before Contacting Insubuy

Before the customer contacted Insubuy for assistance, they tried to handle the appeal on their own and started by paying an attorney to help with the appeal. However, the attorney did not understand that the insurance plan was an international travel health Insurance plan and not a domestic, Affordable Care Act-compliant plan. In the attorney’s appeal, he cited laws and precedent court cases pertaining to the Affordable Care Act demanding payment be made, but since it was not an Affordable Care Act plan, everything in the letter was irrelevant and not useful in helping the customer get their claim paid. The customer spent their money on something that wasn’t helpful.

The customer then tried to write their own letter that focused on how they did not know about the medical condition. In their letter, they cited the medical records that clearly state the medical issue was not known before that day. They concluded that it was not a pre-existing condition and the claim should thus be paid. The problem with their attempt to appeal is that the policy’s certificate wording states that whether a pre-existing condition is known or unknown, it isn’t covered. Another irrelevant letter that was not helpful in getting the claim paid.

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  Pre-existing conditions in Visitors Medical Insurance

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After Contacting Insubuy

After the customer tried everything they knew to do, they contacted Insubuy for assistance. Our Claims Resolution Specialist decided to try, even though the maximum number of appeals had already been made. First, the specialist began by reviewing the medical records and going over the claim. They were then able to explain to the customer in plain English why the claim was not paid. During their review, the specialist discovered that the claims department had missed the acute onset of a pre-existing condition benefit, which not all plans have (but, thankfully, this one did). Then, the specialist reviewed the plan’s certificate wording in great detail with the customer and explained to them what to focus on and include when writing their appeal letter. Insubuy submitted an appeal on the customer’s behalf, and a week later, the claims department overturned its original denial with all related claims being paid.

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  Acute Onset of a Pre-Existing Condition Benefit

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Conclusion

Appealing a denied claim can be difficult because of the many different benefits and exclusions in an insurance plan. Fortunately, Insubuy has the experienced professionals you need to help you understand your unique situation. If your legitimate claim was denied and you would like to appeal, please contact us so we can try to help you. While visitors insurance is available from hundreds of places at exactly the same price for the same product, the added peace of mind and expertise that Insubuy provides is invaluable and comes at no additional cost to all of our customers.