It might be something of an understatement to say that the ski trip that Victor Thomas and his girlfriend Susie took in Zermatt, Switzerland, two years ago, did not go as planned.
On her first day on the slope, Susie fell and shattered her lower leg. She spent the rest of her vacation in the hospital.
Good thing Thomas had bought travel insurance through Access America — or so he thought.
The insurance company “did a great job at that time” he says, paying for the helicopter airlift, losses from trip cancellations and arranging and paying for a first-class ticket home, plus a limo ride back to her house, as specified in the insurance contract.
We were not aware that there was a problem with payment of the hospital bill until we got a phone call from a Swiss collection agency in August of this year. Susie has Blue Cross and they immediately faxed the hospital a certification of coverage and a request to submit the bill while Susie was in the hospital and of which we obtained a copy at that time.
Blue Cross was to cover 80 percent of the $13,000 bill less a $500 deductible. Access America also guaranteed payment of the hospital bill up to the $10,000 medical limit of the travel policy to allow Susie to check out of the hospital. Susie was told by Access America in phone calls, also when she was in the hospital, that they would assist in getting the bill to Blue Cross.
Not to get all political, but doesn’t this sound like one of those case studies they like to mention on the news when discussing health care reform? It also brings up an important question about health insurance portability. But I digress.
The problem arose when the hospital’s billing office failed to bill Blue Cross and started billing Access America instead. In reply to several letters from Access America, Susie discussed the situation with them by phone and was assured that the matter would be taken care of.
We found out last month that Access America finally paid $9,688 (the $10,000 policy limit minus $312 in previously paid expenses) to the hospital on 4/23/2008, leaving an unpaid balance of approximately $3,000.
Then, on 5/15/2008, Blue Cross received a bill for $10,362 from the hospital, over two years after the hospitalization! Blue Cross denied the claim. On 9/3/2008, Blue Cross received another bill for the same amount from the hospital and this time the claim was accepted with Blue Cross agreeing to pay $9,573 of the amount.
So what went wrong? Somehow, Blue Cross paid the wrong party, sending the money to Access America instead of the Swiss hospital.
When I called Access America to inquire how to get them to pay the remaining balance of the hospital bill — about $3,810 — I was told to resubmit the claim for review, which I did.
A few days ago, I received a call from an Access America medical examiner and was told that the claim was denied. She said that since Access America had paid out the maximum $10,000 medical benefit, they were not liable for the remaining balance.
I asked Access America to review Thomas’ case again. And fortunately, it did.
We’ve researched this issue and Dr. Thomas is correct in that we paid the hospital in accordance with our guarantee of coverage. We understand the frustration with the unpaid balance owed to the hospital. To help resolve this issue for our customer, we contacted Ms. Gregg’s primary health insurer and verified that the entire Swiss hospital bill was 13324.35 Swiss Francs. This converted in their processing system to $10,362.09.
Now, the bottom line is what amount Ms. Gregg owes to the hospital. This would be the difference between the hospital bill of $10,362.09 and what we initially paid the hospital: $9,688.72. The difference is $673.37. As we are a secondary insurer in this claim, we were waiting for documentation from her primary insurer in order to determine what additional amount we may have owed.
We have expedited payment in the amount of $673.37.
Lesson learned? Always put your appeal in writing. Thomas called Access America to dispute the bill, and considering the complexity of his problem, he was turned down.
It’s a little-known fact that more than 90 percent of appeals to insurance companies go the way of customers. I think Thomas could have gotten his money back without my help — eventually.
(Photo: Problemkind/Flickr Creative Commons)