Trip Mate cuts it close with definition of “pre-existing” condition

By | October 15th, 2016

It doesn’t take much to incite the commenters on this site to recommend travel insurance. And while it’s true that a good insurance policy can protect your vacation investment, there are always exceptions like John Yuken.

Just hours after he bought a policy through Trip Mate, his appendix burst and he was rushed to the hospital.

A covered event? No, says Trip Mate. That would be a “pre-existing” condition.

Unbelievable.

Yuken’s story — the final chapter of which has not yet been written — is a reminder that the only definition of “pre-existing” that really matters is your insurance company’s. No one cares what you or your doctor, think. Oh, and this is also a friendly reminder to those of you who continually harp on our readers for not buying insurance: Not all insurance works.

Yuken bought his policy through a third party, WorldNomads.com, which is serviced by Trip Mate Insurance, and has faithfully purchased insurance for the last three years.

“Until now we had no complaint,” he says, “probably because until now, we never had a claim.”

But that changed last year, when he booked a 50-day world cruise.

“We purchase the standard plan, that was to take effect October 30 and end on April 30,” he explains. “The cost was $670.”

On October. 27, 2015, Yuken says he felt a “slight pull in my groin area.”

“Normally I would have thought little about it, but since we were going on a long cruise in a couple of days, I visited my doctor, just to be on the safe side,” he says.

His doctor told him he needed to get his appendix removed. Immediately.

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“I thought I might bounce back in time to take the cruise, but my recovery from surgery took much longer than I imagined,” he says.

After much back and forth, Trip Mate denied his claim. It pointed to its definition of “pre-existing” that was included in his policy.


“Pre-Existing Condition” means an illness, disease, or other condition during the one hundred eighty (180) day period immediately prior to the Effective Date for which the Insured, Traveling Companion, Family Member booked to travel with the Insured: 1) exhibited symptoms which would have caused one to seek care or treatment; or 2) received or received a recommendation for a test, examination, or medical treatment or 3) took or received a prescription for drugs or medicine. Item (3) of this [definition] does not apply to a condition which is treated or controlled solely through the taking of prescription drugs or medicine and remains treated or controlled without any adjustment or change in the required prescription through the one hundred eighty (180) day period before the Effective Date.

So it doesn’t matter that Yuken had already purchased his coverage. If he’d exhibited even a symptom within 180 days, he would not have been covered. At least, that’s what his policy says.

Yuken lost $11,157 as a result of this denied claim. Although our advocates have appealed to Trip Mate on his behalf, we are fairly certain the answer will be the same. Trip Mate says it it still reviewing the claim.

The “pre-existing” conditions “gotcha” is the absolute worst in the travel insurance industry. I can’t warn consumers enough about it — and the insurance industry can’t seem to care less. This is similar to the airlines that allow you to assume luggage and seat assignments are still included in your ticket prices, and then hit you with an additional fee at the airport. The less said, the more profit.

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Yuken could have avoided this with a more expensive “cancel for any reason” policy or by getting a “pre-existing conditions” waiver by purchasing his policy at the same time he booked the cruise (some policies let you do that; check the fine print). But other than that, our team has no choice but to close this case.

Should Trip Mate have denied John Yuken's claim?

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  • I, sure Yuken has grounds for a suit, though it would probably be an expensive out-of-state action. Better to trash the company on review sites until nobody else will deal with them. Don’t make anything up, and you’re bulletproof.

  • AAGK

    Ridiculous. A burst appendix is the best example of an unexpected sudden illness. Unless I misread, he booked the trip/insurance prior to the pain. Preexisting vis a vis insurance doesn’t necessarily mean the illness wasn’t in your body, just that you had no indication of its presence. I don’t tend to purchase travel insurance and this is exactly why.

  • taxed2themax

    Insurance is always all about the details– and largely that’s the only thing that matters.. your opinion, other opinions, etc. are pretty much not relevant.. what is relevant is the objective facts that are usually the deciding factor. IF the policy wording was (and was disclosed as such before hand) that it’s a 180 day period — then even at 179 days, I’d expect a denial… 179 is not 180.. Harsh? Perhaps, but to me that’s fair and also sets a precedent of equal enforcement.. everyone who is at or over 180 is fine, everyone is who is not, isn’t OK.. the “line” has been objectively drawn at 180 days and there is only a right or wrong.

    Do I think that this means there is no room for or there should not be exceptions? No, but for me, exceptions are reserved for the most extreme cases and where I can see a clear case for an exceptional action.

    Here’s the other part, and for this kind of venue I suspect it’s not one well received, but none the less, I don’t think it’s fair or reasonable for a business to incur expenses that they rightfully are not liable for. In the case of an insurer, I don’t support them paying claims that – based on the objective facts presented – falls outside of policy wording.

    In this case, I’d need to see, read and understand the exact wording to know; but as a basic idea I fall back to “follow exactly what the policy wording says”

  • Inquirer1111

    I’m confused. When did he buy the policy? Oct 27? When was the trip? Oct 30? I usually buy my policies with my trip so the pre-existing condition doesn’t apply, since my wife has a chronic condition.

  • Michael__K

    The problem is that’s not how these policies are promoted and advertised.

    When:
    You have to cancel your trip due to unforeseeable events outside of your control.

    We:
    Covers the costs to cancel all or part of your trip including other pre-booked expenses in specific circumstances including a sudden illness or serious injury or natural disasters.
    https://www.worldnomads.com/travel-insurance/

    Yet, given the policy language, unless you get hit by a bus, the insurer will virtually always be able to point to some minor symptom from prior months with the benefit of hindsight and call it a ‘pre-existing condition’ and use that to deny claims involving ‘sudden illness.’

    Many will tout that the panacea is to buy insurance with a pre-ex exclusion waiver within the applicable deadline from the purchase date (usually 14 days). However that wouldn’t work either in this particular case — the language of any policy would still allow them to deny the claim on the basis that the traveler wasn’t healthy enough to travel on the date of purchase.

  • Reporter1

    It’s unclear when he bought the policy, but it was to take effect on Oct. 30. However, on Oct. 27, he felt a “a slight pull in my groin area.” He went to the doctor, who said he needed to have his appendix removed. Since this happened before the policy was to take effect, it met Trip Mate’s conditions for a preexisting condition (see contract language above). Had Yukon had his symptoms on Oct. 30 or later, he would have been covered.

  • Rebecca

    I had to read this carefully, but I think I figured it out. They’re not saying the burst appendix was a pre-existing condition. The policy only covered the period starting October 30. His surgery was scheduled October 27th. So, they’re saying the pre-existing condition was the burst appendix itself. The recovery period is what he is claiming under the policy. If his appendix had burst on or after October 30, it would be covered.

    Not that it isn’t bs. That’s terrible and I feel for him. Like you said, that’s the definition of an unexpected medical emergency. The semantics are just more confusing than the article let’s on.

  • AAGK

    You are right. I don’t buy travel insurance, so I don’t really know but why does it start on the 30th? Isn’t it once you purchase it you are covered if you can’t take the trip? I guess he bought a different kind of policy? He should’ve scheduled that Dr appt for the 30th.

  • AAGK

    Why does the coverage start at a seemingly random date? I’ve never heard of that. Full cancel for any reason policies can be prohibitively expensive but this seems odd

  • Stuart Falk

    I buy my travel insurance through USAA which has an arrangement with Travel Insured. They (and most others from the larger insurance companies from what I’ve seen on comparison Websites) are very clear as to whether pre-existing conditions are or are not included. I ALWAYS buy a policy that includes pre-existing conditions, understanding the requirement that such policy has to be purchased within 30 days of making the initial (cruise or other travel) deposit. The mistake here was to knowingly buy a “standard” policy that clearly excludes pre-existing decisions.

  • C Schwartz

    It looks like it was a 6 month policy starting on 10/30 and the illness happened before the policy took effect. I suppose the analogy would be buying car insurance that starts on the 30th and having an accident on the 27th.

  • Michael__K

    No, coverage generally starts when payment is received. However the policies which offer waivers on their pre-existing condition exclusions offer those waivers subject to certain criteria. Among which, typically, the policy must be purchased within 14 days of initial trip payment, and the passenger must be medically fit to travel on the date the policy is purchased.

  • Rebecca

    This isn’t a case of them saying a pre-existing condition is something minor – for example, he had a stomachache 4 months prior and now he’s being denied. This denial is due to the fact that coverage began on 10/30. Since his appendix burst and he required surgery on 10/27, his recovery is what he is actually claiming. The burst appendix itself is the pre-existing condition. Not that I don’t think that’s ridiculous. I do think that’s insane actually. But it IS an important distinction.

  • Rebecca

    I agree it seems very, very odd. I’ve never heard of this either. It doesn’t say when the trip actually was supposed to start, but I assume the trip would conclude before the coverage ended. So maybe the dates default on the insurance website? It should have started 6 months prior to the last day of the trip (or maybe a day or two sooner for cushion?). That’s the only plausible I can come up with.

  • Michael__K

    No, read the policy:

    All coverage (except Trip Cancellation) will begin at 12:01A.M. local time at Your location on the Scheduled Departure Date;

    This was a Trip Cancellation claim so coverage commenced immediately when payment was received. The Trip Cancellation claim, per the article, was denied because of the pre-existing condition clause.

  • Rebecca

    The way I read it was that the coverage didn’t begin until 10/30. That’s very confusing. I’ll have to look through the policy when I get a chance.

  • Michael__K

    The whole purpose of Trip Cancellation coverage is that it covers you before travel. Otherwise, what’s the point of it?

  • Rebecca

    I agree, that’s why I couldn’t understand this. I’d never heard of an effective date like this for trip cancelation. I just assumed it existed because that’s how it’s explained.

    He needs to file a complaint with the insurance commission in his state. Seriously. I read through and found exactly the same thing you did. If they’re saying the coverage wasn’t effective on 10/27, so long as he paid in full by 10/26, they’re wrong. I can’t possibly understand what pre-existing condition could lead to a burst appendix. He’s very lucky this is real insurance and not a protection plan, because he can appeal this with his state insurance commission. And he should. This is outrageous.

  • MF

    As a scuba diver, I’m very familiar with D.A.N. (divers alert network, a nonprofit), which also sells travel, health & evacuation insurance. These policies are open to DAN members (cost ~$35/yr) are much more inclusive than these for profit insurance plans at a generally lower cost. And no, I’m not trolling, look at their website!

  • Michael__K

    I agree it’s outrageous, but we’ve seen this before unfortunately (for example here: http://elliott.org/blog/why-doesnt-travel-insurance-cover-dads-illness/ ) and this practice is apparently tolerated.

    The way all these policies are written, any minor prior symptom is grounds to deny a claim, even if doctors attest that it’s unclear whether the prior symptom was connected to the sudden illness.

  • taxed2themax

    Perhaps…. however, so long as the advertising meets legal and regulatory standards, it is what it is.. As far as the “panacea” claim regarding pre-exclusion waivers goes, I think there will almost always be cases where a traditionally offered policy won’t fit a persons specific conditions and situation — and that’s unfortunate, but in the end, the policy is what it is — and so long as it’s written *and* enforced according to both the policy wording and applicable law, that seems fair grounds to me.

  • Rebecca

    In this case though, they don’t seem to be denying due to a minor symptom. They appear to be claiming the onset of coverage hadn’t commenced. Which completely contradicts their own policy language. I really do think he should file a complaint. I can’t imagine the state insurance commission will allow this. They take things like this very seriously and do indeed act fairly, at least in the few states I’m aware of their actions. Either way, he should win. If it’s an issue with the date, he wins. If they claim a burst appendix is a pre-existing condition, he wins. So, it’s literally a win-win.

  • Michael__K

    We have the best insurance regulatory standards that money can buy….

    https://www.publicintegrity.org/2016/10/02/20020/drinks-dinners-junkets-and-jobs-how-insurance-industry-courts-state-commissioners

    http://www.travelweekly.com/Travel-News/Travel-Agent-Issues/31-states-have-approved-the-sale-of-travel-insurance-by-resident-agents

    We should at least cease pretending that one’s travel deposits are ‘safe’ just because one purchased travel insurance…

  • Michael__K

    They appear to be claiming the onset of coverage hadn’t commenced

    Not sure where you get that from. Per the article:

    After much back and forth, Trip Mate denied his claim. It pointed to its definition of “pre-existing” that was included in his policy.
    […]
    So it doesn’t matter that Yuken had already purchased his coverage. If he’d exhibited even a symptom within 180 days, he would not have been covered. At least, that’s what his policy says.They appear to be claiming the onset of coverage hadn’t commenced

  • Michael__K

    Everything except Trip Cancellation takes effect on the scheduled departure date. However Trip Cancellation coverage takes effect immediately. This is all standard for pretty much any third party policy.

  • Rebecca

    But that changed last year, when he booked a 50-day world cruise.

    “We purchase the standard plan, that was to take effect October 30 and end on April 30,” he explains.

    That’s how I interpreted it. If it took effect 10/30, they were claiming the burst appendix itself was a pre-existing condition and the recovery was the event not being covered.

    In this case, it really doesn’t matter which one of us is right. Either way, he has a case to make to the insurance commission in his state. Under both scenarios, he should be able to successfully appeal this. If it’s procedural or if Trip Mate is claiming a pre-existing condition caused his burst appendix, they’re wrong. Legally wrong.

  • Michael__K

    That has nothing to do with the insurer’s denial. You need to include the previous sentence for the context:

    “Until now we had no complaint,” he says, “probably because until now, we never had a claim. But that changed last year, when he booked a 50-day world cruise.”

  • taxed2themax

    I agree that the lobbyists is a cause for concern, and I am sure there have been illegal practices in the past.. but.. that for me does not mean the regulator is nothing more than an industry ‘rubber stamp’ if you will. I believe that the regulator (and further the judiciary as well) acts as a reasonable balance between the consumer interests and the opposing corporate interests.

  • Michael__K

    Of course not every state regulator is merely a rubber stamp. But it’s extremely wishful thinking to believe that there is overall “a reasonable balance between the consumer interests and the opposing corporate interests,” especially when nothing is done to address known issues and especially when the trend is for sellers of travel insurance to be exempted from the reach of insurance regulators in more and more states.

  • PsyGuy

    I hated voting yes on this, mainly because I’d have read the exclusions and realized this policy would not have been for me, and it isn’t that difficult to find. What bothered me is that 180 days essentially makes any medical claim that isn’t catastrophic trauma a pre-existing condition.

  • Michael__K

    What policy (from any company), other than Cancel for Any Reason, doesn’t have exclusions which could be used to deny this claim?

    Even CFAR would be dicey: the CFAR deadline is normally 48+ hours before the departure date. It’s not clear if Mr. Yuken would have had the presence of mind and the means to provide written notice of cancellation by 11:59pm on Oct 27.

  • Charles Owen

    On 10/5 I purchased a TravelGuard policy for a trip we are taking in November. The effective date as indicated on my policy is 10/6. The policy indicates “Trip Cancellation and Cancel for Any Reason coverages will be effective at 12:01 a.m. Standard Time on the
    date following _payment_ to the Company of any required plan cost”. Now, I ALWAYS get a preexisting condition waiver, since that’s the easiest thing in the world for an insurance provider to use against you.

    I don’t understand why his policy was not already in effect. Was 10/30 (or 10/29) when the agency processed the payment? When did he actually purchase the policy? This one really makes no sense.

  • Michael__K

    TripMate has the exact same Effective Date provision as TravelGuard for their Trip Cancellation coverage (12:01am on the date after purchase).

    It’s seems clear the Trip Cancellation coverage was already in effect, or else TripMate would have no need to cite their Pre-Existing Condition clause as their justification to deny the claim.

    TravelGuard could have denied this claim just as well, even with a Pre-Ex waiver, on the grounds that the “slight pull in the groin area” meant that the insured was not fit for travel on the date of purchase.

  • taxed2themax

    Perhaps.. I tend to see it, as I framed it “a reasonable balance” however, as this is a subjective matter, I cede that there can be differing opinions. As far as the claim “nothing is done…” goes, here too, I think the regulators must look at see what is the best balance of regulation, I do not think regulation should unduly favor either party.
    Granted, I suspect folks on either ‘side’ of this issue can cite websites, blogs and piece meal data to support their viewpoint.. and that’s probably all true.. but in the end, for me at least.. wishful thinking or not withstanding, it is my viewpoint that the regulator does far more good for the consumer than bad.

  • sirwired

    I’m confused; did he not buy insurance it AFTER he felt sick enough to call a doctor? (All the cancellation coverage I’m aware of takes effect a minute past midnight that very night.)

    Buying insurance to pay for the proverbial animals AFTER you get an hour away from home and think you left the barn door open is not what insurance is for.

    If he was a “faithful insurance customer” why would he wait so long to buy a policy?

  • Michael__K

    So what is the (recent) evidence on which you base your viewpoint?

    And what do you believe regulators are doing to counteract lawmakers who have reduced their authority, particularly with respect to sellers of travel insurance?

  • cscasi

    Unless he has a “pre-existing conditions waiver” included in the coverage he purchased; which he did not. I don’t know if the insurance company offers that as an add on or in a higher cost policy. In any case, he did not have that and he was not covered.
    I have had to use the pre-existing waiver twice and both times, the company paid my claim in full because I had the waiver included in the policies; once because I had to have a gallbladder operation (the lab tests came back the day before I was supposed to travel) a few days after my travel would have commenced and once for an issue with some new treatment I began for common immune deficiency made me ill enough that I could not travel. Both times, completed the claim forms (they e-mailed me), have the doctor fill out the doctor form the insurance company wanted completed, and include the proof of purchase of the airline tickets (and any nonrefundable costs for hotel/tours/etc.); fax it in and within a week, I received notification that the claim was processed and within less than a week after that I received the payment check; both claims.
    Do all claims with all travel insurance companies go as smoothly? I would like to think so, but we here know different. But, I feel that using a good reputable insurer and making sure you purchase a policy with the coverages you want, is paramount. And, you can always ask the insurer questions before you actually purchase the policy and even have “x” amount of days after you receive the policy to examine it, ask questions if you have concerns and even cancel it without charge if you don’t feel it it what you want.

  • Michael__K

    None of the policies currently offered on WorldNomads.com for US residents has a pre-existing conditions waiver.

    And even if it did, I explained above why I wouldn’t expect it to make any difference in the outcome of a case like this one — the groin ‘pull’/pain could be cited as evidence that the insured was not medically fit to travel when the policy was purchased.

    You can ask the insurers as many questions as you want before purchase, but the policies are clear that the policy language takes precedence over any answers you receive.

  • Fred

    Based upon the explanation from Tripmate, this policy has no “trip cancellation insurance” unless your medical issue happens at say 1:32am on the day of departure. Therefore this policy is only for “trip interruption”, at best. AND I would consider this policy a scam. I would file a fraud complaint with the state insurance commissioner.

    The exact language from Travel Insured, in a current standard policy purchased this month is:
    “Trip Cancellation: Coverage begins at 12:01 a.m. on the day after the date the appropriate premium for this Policy for Your Trip is received by the Company or its authorized representative prior to the scheduled departure time on the Scheduled Departure Date of Your Trip. This is Your “Effective Date” and time for Trip Cancellation.”

    This is the language in every policy I have ever seen from Travel Insured and Travel Guard; the two respected travel insurance companies I deal with often. (I see these all the time, as I am a travel agent).

    My own direct experience, in 2011:
    Purchased trip in March 2011 for travel in late June of same year
    Purchased travel insurance within 14 days
    Had a heart attack (and stent surgery) on June 9th
    Was out of the hospital within 3 days
    Dr. stated I could not travel by air (especially not for an extended flight over the ocean) for at least 60-90 days.
    Cancelled trip and filed insurance claim right away. Provided paperwork requested by Travel Insured, from my doctor.
    Had a check for the full cost of the trip in my hands in less than 21 days.

    I have never sold TripMate and I have never heard of WorldNomads. But I do believe if the words “trip cancellation coverage” appears anywhere in their policy they should be prosecuted for insurance fraud. If the words do not appear, why would anyone buy this crap? Trips get “canceled” before the date of travel. Trips get “interrupted” once the date of travel is here. I would love to read the actual policy. I will add these two companies to my “never deal with!!” list.

  • Tigger57

    Unbelievable! I am glad we don’t sell Trip Mate!

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