Two Canadian seniors have been "blindsided" by $100,000-plus in U.S. medical bills, despite buying full coverage travel insurance for trips south.
"It’s just been a terribly, terribly stressful few months," said Joanne Parr, 67, of North Bay, Ont.
"It just threw me for a loop totally," said John Toljanich, 74, of North Vancouver, B.C. "I am on anti-depressant pills now, for the first time ever … because of this claim."
Both were treated in U.S. hospitals last winter. Their illnesses were sudden and unrelated to any pre-existing conditions.
Their insurance claims were denied because Parr and Toljanich each made what they call an honest mistake when answering a question on their initial application form, about past treatments for other ailments.
"I would have sworn on my life that I filled everything out correctly. With my sight, I check everything I do three or four times," said Parr, who is legally blind and used a magnifying glass to fill out her form.
"It makes no sense to answer something incorrectly. Why even pay the premium? You are just throwing money out the window," she said.
Medical records scrutinized
Their insurance companies found the discrepancies later, by digging through the claimant's Canadian medical records, after the bills were submitted.
"What they do, in my opinion anyway, is if a claim is anywhere in the thousands of dollars, that’s when they go over it with a fine-tooth comb and look for any excuse not to pay the bill," said Toljanich.
He was treated in California for a nasty bout of pneumonia, which he said he's never had before. The question that tripped him up, on Manulife’s online application form, was whether he had been treated recently for several other conditions, including bowel disease.
"The one that I ticked wrong and I said no to was the chronic bowel disorder. I didn’t have a chronic bowel disorder. And that’s the thing that caught me."
Toljanich has ulcerative colitis, but he said records show it’s been in remission for decades. He said he’s had no symptoms or treatment for it since 1965, so he didn’t consider it relevant.
He takes a drug that prevents flare-ups, though. The company that handles Manulife claims told him that is considered "treatment," so he should have answered yes.
"They call it fraud on my part – or misrepresentation. It said that right in the letter," said Toljanich.
In Parr’s case, she misunderstood a date requirement when she filled out the form for insurance with Royal and SunAlliance, sold online as Southbound Travel Insurance.
She was asked if she’d been treated for heart problems in the 12 months prior to applying for insurance in August 2011. She answered no, even though she’d been to hospital with chest pains the previous October.
Parr and her husband Chuck weren’t leaving for Florida until December 2011. She said she thought the question applied to the 12 months prior to that date, because that is the benchmark she’s accustomed to from other insurance policies.
"My mind was thinking departure date, because that is when I was paying my premium from," said Parr.
"There’s one question right after the one they got me on — another question about your heart — and I answered yes to it. So, it just kind of proves that I didn’t try to get away with anything."
Parr was treated in Florida for kidney failure, which she’s never had before.
"The insurance company went back seven or eight years [scanning medical records] trying to find something wrong with my kidneys but they had no luck," she said.
Royal and SunAlliance refused to comment on Parr’s claim and appeal, although she was willing to give permission for the company to speak about her case.
"At RSA, we are committed to protecting the privacy of all our customers. We take this commitment very seriously and cannot go into detail about individual policies or claims, including this one," said spokesperson Scott Tabachnick.
Submit your story ideas:
- Go Public is an investigative news segment on CBC-TV, radio and the web.
- We tell your stories and hold the powers that be accountable.
- We want to hear from people across the country with stories they want to make public.
"We offer all customers a comprehensive appeals process, in the small number of situations where it is required this ensures all decisions are made with the utmost consideration and care."
Manulife confirmed Toljanich’s appeal is being considered, but wouldn’t say any more about his case.
"It is currently under review. As this is an individual claim matter and we take the responsibility of protecting the privacy of our clients very seriously, I'm not able to speak further about the specifics of this case," said spokesperson Jana Miller.
"Manulife Financial reviews each individual claim in great detail, taking into consideration all of the information we have. The decision to deny a claim is not taken lightly."
Both Parr and Toljanich fully recovered from the conditions they were treated for in the U.S.
Parr's bill is approximately $128,000, while Toljanich's is $112,000. About one-fifth of their bills is for flights. Both said they wouldn’t have agreed to be airlifted home if they knew they’d be on the hook for the cost.
"I just can’t afford that kind of money. That’s a lot of money," said Toljanich. He and his wife, Lorraine, would have to borrow against their home, he said, and then pay interest only on the loan.
Parr’s husband Chuck said, "I’ve talked to the bank. We can remortgage our home. But I don’t want to start all over in life again."
"The deck is stacked in the insurance company’s favour," said Ottawa independent insurance broker Bruce Cappon, who said he’s seen several claims by seniors denied because of what he calls the "one strike you are out" clause.
"Coupled with the complicated medical questionnaire, it seems like the snowbird is often having a stick of dynamite in one hand and a lit match in the other. It’s a very volatile situation."
He suggests senior travellers be wary of policies with the one strike you are out clause, and the "open barn door" clause, where unreported changes in health status between application and departure can result in cancellation of a policy. He also warned about policies that don’t cover pre-existing conditions.
If a claim is denied, he suggests seniors fight back — possibly with help from a lawyer or an insurance broker — by appealing to the insurance company and then the firm's ombudsperson.
"I think they’ve got to stand up on their own two feet and push back."
If that fails, he said, U.S. hospitals will almost always discount bills by at least 30 to 50 per cent.
One case in point is Anna Friesen of Abbotsford, B.C., whose story was featured by Go Public a year ago. A mistake on an insurance form left her with a $53,000 bill for treatment at the El Centro Regional Medical Center in California. She appealed to the hospital under its "financial assistance" program, and her entire bill was forgiven.
"There is always wiggle room to negotiate," Cappon said, "Even the insurance companies don't pay [hospitals]
the full ticket price."