If your travel insurance claim is denied, knowing how to file an appeal can be very useful, especially if you think that your claim was legitimate and denied unfairly.
Many travelers understand the importance of buying travel insurance when traveling outside their home country. They pay for the premium, receive the policy and expect that they will be covered if something happens to them while on their trip, which is not always the case.
Terms and conditions
All travel-insurance plans, just like any insurance plans, have their terms and conditions, listed in the certificate wording. All U.S.-based insurance companies are required by law to treat all the insureds the same and adjudicate the claims according to the terms and conditions of the policy. If they deviate from that and start making exceptions, they may be fined by the government and may even be shut down.
Certificate wording is available to read online (right on this website) before purchasing the insurance policy. Additionally, the same certificate wording is also sent to the insured by email or post after buying the insurance. It is the insured's responsibility to thoroughly understand what the policy covers, what it excludes and what the terms and conditions are for coverage and claim.
In case of any questions or clarification, it is also essential to consult a licensed and experienced travel-insurance agent who can explain the details of the policy, before it is too late.
Ignorance or failing to understand the insurance policy that you bought is not a valid excuse to get your claim paid.
According to the United States Travel Insurance Association, one out of every six insureds ends up filing a claim, and less than 10 percent of those claims are denied.
If your travel insurance claim is denied, you may be upset, and you may be outraged. However, getting upset is not going to help you. Therefore, the first step for you would be to calm down and make sure that your claim is indeed legitimate. Read the certificate wording thoroughly.
Filing an appeal
If you genuinely think that your claim is legitimate and it has been denied unfairly, you should file an appeal.
If your claim was denied because you didn't file a claim form, or your medical records were missing, or documentation was missing, you should immediately submit them to be reconsidered.
However, if you followed all the procedures, and the claim was still denied, the denial can be appealed.
Once the claim is denied, the insurance company will send you an explanation of benefits (EOB) and optionally another document that will specify why the claim was rejected.
Each insurance company has a specific procedure and a time frame (usually 30, 60 or 90 days) in which you must file an appeal, as specified in the certificate wording. If you are past that deadline, you can't file an appeal even if the claim was otherwise payable.
To file a compelling appeal, you must understand the reason for the claim denial and be ready to provide the documentation that substantiates why your claim should be paid. You could give a letter from the doctor, the past medical records and any other pertinent information that would help the insurance company reconsider the claim. If the claim was denied due to pre-existing conditions, a letter from the physician describing why it should not be considered pre-existing condition might help. If the claim was denied by the insurance company not considering it medically necessary, a letter from the physician describing why they thought it was medically necessary might help.
In addition to providing the documents from third parties, you should also write a cover letter explaining why you think your claim should be covered and what kind of documents you have attached substantiating the same.
Merely filing an appeal without any basis is very unlikely to help you to get the decision reversed.
If you have purchased the insurance through a reputed broker such as Insubuy, they can help with filing an appeal for your legitimate claims.
Make sure to send the appeal by certified mail with return receipt to make sure that the insurance company receives it. As the appeals process can be slow and may take some time, make sure to follow up with the insurance company periodically to check the status of the appeal.
If your appeal is denied, and if you later find that you have more documents that could help overturn the decision, you can file an appeal again.
Instead of reading the terms and conditions of the policy, instead of taking the professional advice of the broker (if they provide any), instead of understanding the true reason for the denial of their claim, some people simply start posting negative reviews about their broker and/or the insurance company trying to bully them into some action. That simply does not work. Read about reviews on the internet and social media.
Some people try to threaten to the insurance company that they would file complaints or sue them if they claim is not paid. However, if their claim is clearly not payable to begin with, no amount of complaining is going to help get it approved.
While the vast majority of legitimate travel-insurance claims are paid without any problem, if your legitimate claim was rejected due to missing documents, clerical error, misunderstanding, lost documents or due to a gray area, then you should file an appeal to try to get your claim approved.