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191 calle Magdalena, suite 270 • encinitas, San Diego County, ca  92024 • 760-436-8832

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DON’T LEAVE HOME WITHOUT THEM!–Part 7

Introduction
Links to Prior Articles on this Subject
Emergency Evacuation Insurance
Evidence
When Negotiation Breaks Down
Bad Faith
Resolution

This is a continuing series of articles with a number of "parts." See Table of Contents and search for "Don't Leave Home Without Them" and "Don't Leave Home Without It."

Introduction: We continue our discussion about my wife’s and my five day adventure in an Argentine hospital due to a bout with pneumonia. As I have said previously, my wife is fine now and doing well. This month we continue to deal with the very important subject of obtaining reimbursement on your trip insurance. (back to top)

Links to Prior Articles on this Subject: So far we have discussed travel insurance that should be purchased, medical insurance, costs, and coverage, smart phone and apps people should have with them if they are caught in a medical emergency in a foreign country, money issues and solutions in such a situation, and trip insurance and obtaining reimbursement. (back to top)

Emergency Evacuation Insurance: As easy as the other two claims were was as difficult as this one was. If you are unfamiliar with this insurance, here’s a link to a prior article on Emergency Evacuation Insurance. After I filed the claim packet (with all of the supporting documentation and my explanatory cover letter), I received a letter from the company that my claim was denied due to my failure to have the program administrator involved in the evacuation (the ground ambulance and all of the transportation from that point home). Since the administrator keeps case notes on every phone conversation as well as recording the phone calls (at least that’s what they told me at the time) they either did no investigation of my claim or were hoping that I simply went away. Attorneys don’t generally do the latter and since my cover letter was on my letterhead, I was surprised they tried this tactic with me. (back to top)

Evidence: Although I did it politely, I felt like sending them a letter that said, “What have you folks been smoking?” I reminded them that the cruise ship physician spoke with them before my wife was ever taken off the cruise ship and I still had her handwritten note with the claim number they assigned. Obviously, if a claim number had been assigned before we left the ship, they must have been involved prior to the ambulance trip. Further, I had my cell phone bill that detailed each call I had made to the phone number of the administrator as well as the duration of the call and the time and date. Then there was the important fact that they had changed the air reservation as well as making the reservation for the service to pick us up at the San Diego airport for the ride home. Those polite and pleasant reminders got the claim back on track. (back to top)

When Negotiation Breaks Down: They then asked for more documentation, basically the medical insurance EOBs (Explanation of Benefits), which I provided, and then approved my claim—but only for the portion of the ground ambulance that was not paid by the medical insurance. Another letter from me pointing out that they needed to tell me why they were refusing my other line item expenses (the car service home, the half day hotel room in Houston during an extensive 10 hour layover allowing my pneumonia recovering but severely weakened wife to lie down, the increased air fare to fly home, and various other charges). I quoted them line and verse from the policy booklet as to why each line item should be covered. And then I used the phrase that insurance companies just hate to hear----“bad faith settlement.” (back to top)

Bad Faith: If an insurance company acts in bad faith to settle a claim all of a sudden they, often, can be on the hook for the insured’s emotional distress, punitive damages, etc. So the $1000 claim can grow into a $30,000 claim. Not what an insurance company wants. That letter prompted a phone call from the claims adjustor.

The claims adjustor explained that all charges for the trip home were not covered as the coverage was only for evacuation to the hospital where my wife could be treated. I expressed dismay since the policy booklet expressly includes the trip home from the hospital for recovery. She said I must have an older version and she would email me the later version. As she was about to send me the link, I asked what the revision date of the new version was. Turned out it was the same revision date as the booklet I had. Now, she expressed dismay.

The adjustor asked me for the page and paragraph number of the “trip home for recovery” coverage. I told her, she looked and was surprised to see it there. Several times she went to speak with “management” during our conversation. Finally, she came back and said they won’t cover. That’s when my patience started growing thin and the volume level started to increase.

Essentially, I said that I had told her company in my letter why I thought things were covered and now it was their duty to tell me why they thought it wasn’t. Then we’ll just put it in front of a judge and let him decide. I told her I was confident the judge would rule in my favor; were they confident in their position. As the conversation became more heated and I started asking if they just deny, as a matter of course, and hope people go away, her position changed. All of a sudden she said just give us 48 hours and we will respond. (back to top)

Resolution: The next day I received a letter by email approving most of the remaining line item expenses and denying one with an explanation. They denied the remaining hospital bill (the co-pay portion not covered by my medical insurance) on the basis that that was not part of the “evacuation.” After thinking about that for a while and pondering on the meaning of “evacuation,” I came to the conclusion that they were probably right on that issue so I accepted their increased payment and closed the claim.

Next month we will deal with drug coverage and final thoughts on what will probably be our last article on this discussion.

This is a continuing series of articles with a number of "parts." See Table of Contents and search for "Don't Leave Home Without Them" and "Don't Leave Home Without It." (back to top)

July 10, 2016
 

   
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