Do employees know enough about their coverage?
It was supposed to be a relaxed vacation in Hawaii, but Canadians Jennifer Kimmel-Huculak and her husband Darren soon found out their November 2013 getaway would cost much more than they bargained for.
Jennifer was 24 weeks pregnant at the time and ended up delivering a daughter by emergency C-section at a hospital in Hawaii. The price tag? $950,000.
And while the couple had purchased travel insurance from Saskatchewan Blue Cross before the trip, their claim was denied, with the insurance company citing nine specific (but undisclosed) events.
“The challenges facing this family are extraordinary and difficult. As such, we urge Ms. Huculak to have our decision reviewed by an independent ombudsman,” said Arnie Arnott, president and CEO of Saskatchewan Blue Cross, in a release.
It’s a gut-wrenching situation, according to Alex Bittner, Toronto-based president of the Travel Health Insurance Association of Canada (THiA).
“The last thing the insurer wants to do is turn down that claim — can you imagine the reputational risk that Blue Cross is going through right now? They absolutely do not want to decline a claim but they have to and if it’s not payable, it’s not payable.”
With winter upon us, many employees are heading to sunnier locales, but how many are fully aware of the health coverage provided in their travel insurance?
Forty per cent of Canadians don’t know what kind of travel insurance coverage they have while 67 per cent don’t know if provincial health plans cover out-of-province medical care, according to a 2014 survey of 1,007 Canadians by the THiA.
“A lot of them are crossing their fingers and hoping that everything is fine,” said Bittner. “At the end of the day, insurers do want to pay claims and (for) consumers, we talk about financial literacy and all that stuff, they also have a responsibility to know about their insurance and crossing your fingers and hoping for the best isn’t the best strategy.”
Although group insurers in Canada are required to provide a description of benefits (typically in a plan member benefits booklet) that details a plan member‘s coverage, not all members take the time to read and fully digest the coverage available under their plans, according to Mark Rolnick, assistant vice-president of product development, group benefits, at Sun Life Financial in Toronto.
“Since travel benefits are less frequently used, as compared to a drug benefit or dental care, plan members tend to gloss over the information or forget they even have travel coverage until they are just about to leave on their trip.”
Variations in coverage
When you’re dealing with travel insurance policies or disability policies, you’re going to see common elements but you’re also going to see variations, said Sivan Tumarkin, a partner specializing in personal injury and insurance at Samfiru Tumarkin in Toronto.
“Some policies will identify all the pre-existing conditions that will exclude you from getting coverage. Some other policies may list different conditions,” he said. “Some of them will attempt to identify pre-existing conditions but you as a layperson may not necessarily understand what it is that they mean.”
It is sometimes difficult to determine when a pre-existing condition was diagnosed, treated or stable before travel, or if an emergency medical event during travel is connected to a pre-existing condition, said Rolnick.
“At times, the situation is not clean-cut. The historical medical records of a plan member may be requested in order to help determine if a medical emergency they had while travelling is related to a pre-existing condition.”
Previously, when it came to group plans, pre-existing conditions were not normally an issue, said Bittner.
“What we’re finding now though is that insurers are putting in clauses that require one to be stable prior to departure. And I think, frankly, it’s because of the burgeoning costs of health care relative to the premium.”
Group plans and individual plans alike tend to cover many of the same eligible expenses for emergency medical care outside a member’s home province or Canada, such as the cost of a physician, surgeon, hospital room and board and medically necessary diagnostic tests, according to Rolnick.
The areas where travel insurance coverage is more likely to vary are with the time frame of the benefit maximum, the dollar maximum of the benefit, maximum travel duration or limitations such as a pre-existing condition exclusion that excludes any coverage for an individual if she has a medical emergency while travelling that was related to a condition she was diagnosed with, or received treatment for, prior to travelling, he said.
Employee tips
When it comes to travel insurance, there are three core principles, said Bittner: know your trip, know your health and know your policy. That means consulting with your doctor, knowing the specifics of your destination — such as activities you’ll be doing — and going over the details of your plan.
“In a perfect world, (if) I’m pregnant, I want to go away somewhere, I am going to now hound either my employer — or they’ll route me through to my insurer — but I will hound them for the specific policy wording around pregnancy because they’re not all consistent, not every policy is the same,” he said.
“It now behooves the employee to find out what the exclusions are. And I think it behooves the employer, incidentally, to get that information out to them as well.”
Employees should read their policy and know what’s covered, specifically the exclusions and what’s required to be covered, said Tumarkin, such as notifying the insurance company within 24 hours of a medical emergency or having the hospital or medical doctor get in touch.
And if a member is a resident of Ontario, for example, he should immediately check with the Ontario Health Insurance Plan (OHIP) when there’s a medical emergency because some travel insurance policies will say they are secondary to OHIP, he said.
“That’s very, very important because sometimes that’s a condition for coverage of the insurance policy.”
Plan members should refer to the travel benefit coverage details in their benefits booklet before travelling and call their group benefits insurer if they have any questions, said Rolnick.
“For employers who do regular internal newsletters or communications to their staff, a reminder like this before typical high-volume travel times (in summer and late fall) can be a helpful trigger for members to reacquaint themselves with their travel coverage.
“The employer can also ask their benefits advisor or insurer if they have any communication specific to travel benefits or travel tips which they can provide to their staff.”
