A Cautionary Tale regarding Serious Illness Outside the United States
Today’s video describes a distressing series of events which underscores the importance of purchasing one’s own Travel Coverage policy when leaving the United States. Even in those instances where your group policy or Medicare supplement has a travel coverage benefit, in our view it is always wise to consider purchasing travel coverage. Without this coverage, it’s possible you could be left to fend for yourself during illness or injury in a foreign country. When traveling abroad you want to know there is a provider obligated to help identify where you should receive services, what doctors should be involved, arrange translation services, when needed, make the arrangements to transport you, if necessary, and to cover the cost of services consistent with your coverage should illness or injury occur. Having travel coverage as part of employer-based coverage or in a Medicare supplement is better than not having it at all, of course, but, worst case, you may have to incur out-of-pocket costs up front and be reimbursed as well as receive minimal or no support during a personal emergency. In sum, carefully review your benefit if you have one to determine the level of service that will be provided should illness or injury occur abroad. And if it isn’t clear what level of service will be provided, you should inquire to obtain as much information as possible.
The gentleman who became our client after his claim for air ambulance services was denied, sustained a sudden, life-threatening illness in May 2021 when he was 30 years old. He was a totally healthy young man staying on a Caribbean island with his fiancée and future father-in-law when he sustained a life-threatening AVM, or arteriovenous malformation. Our client’s AVM was life-threatening due to a rupture accompanied with extensive hemorrhaging. His employer-based policy clearly included coverage for emergency services and air ambulance services while outside the United States. The good news is that he is doing fairly well at this point, but the insurance journey was quite treacherous.
Our client was unconscious as a result of the AVM but his fiancée and her father were in immediate contact with his parents who were in immediate contact with his insurance company’s Air Ambulance and Out of Country Services, Clinical Advocacy and Support Department. The hospital where he was admitted arranged for transfer to a hospital on a larger island where it was determined that the sophisticated neurosurgery he required could only be done in a major medical center.
During this time, our client’s parents remained in contact with the son’s insurer’s Air Ambulance and Out of Country Services Department. They were told the two in-network air ambulance providers were not available for immediate transport. What should have happened at that point, in my opinion as a former health plan executive, is that the Department should have negotiated what is referred to as a single case arrangement with another air ambulance company and worked with the family to develop a plan for transport and subsequent surgery.
Because the insurer’s Air Ambulance and Out of Country Services Department was not moving decisively to arrange services for their son, our client’s parents filled the void. They contacted a nonprofit organization involved in AVM research which helped them identify a highly-regarded neurosurgeon in Miami who was available to do the surgery. The surgeon was also in-network with the son’s Plan. They also contacted air ambulance companies, obtained quotes, and negotiated an agreement for evacuation, which included a significant upfront payment of over $50,000. During this process, the family regularly communicated with the insurer’s Air Ambulance and Out of Country Services Department and their primary contact acknowledged that the Air Ambulance Company they planned to use was reputable.
The parents were also told that the air ambulance claim would be considered out-of-network. Yes, technically a non-contracted provider is out-of-network. However, as mentioned previously, the insurer should have made the arrangements and the insurer should have guaranteed payment but for in-network cost sharing obligations. If this incident had occurred in 2022 rather than 2021, there would have been more protections for the family through the federal No Surprises Act.
Although the numerous email exchanges between our client’s mother and the insurer led the family to believe these services were covered, the insurer initially denied the claim altogether. This was astonishing. Their rationale as stated in the Notice of Adverse Determination is as follows:
Clinical rationale (for denial): This facility is closer and has neurosurgery. Auxilio Mutuo Hospital of Puerto Rico. Ponce de Leon Avenue, Stop 37 ½ Hato Rey, PR 00919. So the reason for the transfer to the farther facility is unclear.
Of course, the family might have considered this alternative if the insurer had worked with them to arrange transfer to a medical center in Puerto Rico. The fact is that the insurer abrogated its responsibility to its member and then, quite unbelievably, denied the claim.
We were retained at this point and recommended appealing the insurer’s denial. Our objective was to help recoup the substantial deposit the family made to the air ambulance company for the evacuation but let’s be clear. The family had no expertise in making emergency evacuation arrangements and the insurer’s department has that expertise. The insurer’s inaction left its member at great risk. At any rate, we drafted the appeal and the denial was overturned. Winning an appeal is always an important step in recouping money from an insurance company but the ultimate objective in this situation was for the family to recoup the substantial advance payment made to the air ambulance company.
Meanwhile, the air ambulance company had submitted claims to the insurer for a substantial amount and the family had also submitted claims requesting reimbursement for their upfront payment. The insurer outsourced the whole matter to a third-party vendor to negotiate a settlement with the air ambulance company. Communication from this company was inscrutable as were the explanation of benefits statements on our client’s website.
During this time the family and my staff and I contacted other representatives of the insurer to urge expedited payment to the family because some representatives suggested the family obtain reimbursement from the air ambulance company. In an environment where the air ambulance provider and insurer are at odds over the appropriate payment amount, it is entirely unrealistic to think the provider will refund to a family. At times resolution with the insurer appeared promising but ultimately remained elusive.
After months of effort, I recommended that we file a Grievance with the New York State Financial Services Department which had jurisdiction over the insurer. The Grievance was filed in early May 2022, a year after the medical evacuation occurred. In August a check for the full amount the family had paid up front to the air ambulance company was mailed to their son, the insured, along with an explanation of benefits statement.
Although we were pleased that the family was reimbursed after so many months of intense effort, we remain totally dismayed at the actions of this insurer and that there will likely be no repercussions to their failing to meet their contractual obligation to our client or his family. Their likely motivation in sending the check is that the New York State Financial Services Department publishes statistics of such complaints and ranks insurers by the number of complaints that are overturned. By finally reimbursing our client, the insurance company essentially removed this dispute from the process. They obviously thought they would lose and since their ranking among the 40 insurers rated was near the bottom of the list, didn’t want to worsen their position. You can download the 2021 report here.
I don’t believe such bad behavior on the part of commercial insurance companies has to exist but it does. The lesson here is to be sure you have the support you need should you have a medical emergency while traveling outside the United States. Your life could depend on it.