Navigating undeclared pre-existing conditions
Dr Lynn Gordon, Chief Medical Officer at Charles Taylor Assistance, shares what happens for the assistance company when undeclared pre-existing conditions get in the way of travel insurance coverage
Pre-existing medical conditions (PEMCs) have come under the spotlight in the UK this year, not least because retail travel insurance vendors are now obliged to signpost customers with serious PEMcs to an approved directory of providers. This, says the Financial Conduct Authority (FCA), should help those with PEMCs navigate their options and avoid paying over the odds for cover. It should also reduce the number of uninsured travellers who risk paying large medical bills if an emergency strikes overseas. The FCA is also working with the travel sector to drive a wider consumer understanding of PEMCs in relation to insurance. And this is good news for insurers and medical assistance providers alike.
But what about the minority of customers who buy travel insurance and find themselves not covered for medical assistance overseas because of undeclared PEMCs? And how should assistance providers, on the frontline of medical claims abroad, respond?
Looking at the causes of undeclared conditions
The Customer Insurance (Disclosure and Representations) Act 2012 requires customers to take reasonable care not to make a misrepresentation if asked a clear question by an insurer when a policy is sold or renewed.
Nevertheless, a small number of travel insurance customers choose not to declare pre-existing medical conditions; perhaps for fear of expensive premiums, or of employment repercussions (for instance, if they expose mental health problems), or of not being eligible for travel insurance at all. Others may be unaware of the conditions they need to declare. Others still may forget to update medical information for existing travel insurance policies when their health has changed.
What we do know is that there’s no single reason for pre-existing conditions, physical or mental, not to be declared by consumers – and that reading the policy small print is a vital part of making sure that cover is adequate.
To cover or not to cover?
A skilled manager can make all the difference to a customer’s understanding of the fairness of the claims process, and to the ongoing relationship with their insurer
It’s up to the underwriter to decide whether or not to pay a medical claim. But it falls on the assistance provider to determine if customers’ pre-existing medical conditions have been declared correctly, and, if not, if they are relevant.
The provider has a responsibility to both underwriter and customer to carry out this process fairly, transparently and thoroughly. And the pressure is on to minimise delays, especially when a customer is being treated in a private hospital and the medical bills are mounting, or if care providers are impatient for guarantees of payment.
In the face of potential delays (for instance when primary care practitioners are slow to produce the medical records needed to establish cover), customers can be asked to sign disclaimers to declare they have been open about their PEMCs. The assistance provider can also dig deeper using techniques such as retrospective medical screening to determine an individual’s health status when they took out a policy, and further GP questioning. These can help establish if, for example, a customer’s symptoms were apparent before they set off abroad, if they truly understood what their pre-existing conditions were, if they were waiting for a referral to a specialist – and so on.
Setting the right expectations about cover from the start of a claim is important. For instance, if a customer has been involved in an accident abroad, their assistance case manager should make them aware that the insurer will establish if there were contributing factors, such as pre-existing eyesight problems, before confirming cover.
If a claim is subsequently denied by the underwriter, the case manager will need to explain this with extreme sensitivity, possibly in the face of anger and upset from the customer. A skilled manager can make all the difference to a customer’s understanding of the fairness of the claims process, and to the ongoing relationship with their insurer. Full and seamless support via self-funded assistance or repatriation should be offered in these situations, and some customers will choose this option, especially when they are very sick and need help to get home. Others will organise their own transport home, or stick to their original travel plans if they are well enough to do so.
Sometimes, when a travel policy would have been sold at a higher premium if all PEMCs had been declared at point of sale, the case manager will explain that the insurer will pay a proportion of the claim; for instance, 60 per cent of air ambulance costs, with the customer asked to pay the remaining 40 per cent. In all these circumstances, the assistance provider must do everything in its power to determine a fair decision.
Prevention is better than cure
It’s important to convey the message that travel cover can’t be taken for granted. As the Financial Ombudsman Service states: “Travel insurance can be the most complex financial product an individual may buy during the year because of the wide range of risks covered.” Customers need to view it as more than a last-minute ‘add on’ to a holiday, which means recognising the relevance of PEMCs.
Automated medical screening with intuitive question sets, industry campaigns and media coverage are all increasing awareness of the importance of declaring pre-existing conditions to validate travel policies. Wider digitisation may also help drive the cause, for instance via individual pre-travel health risk assessment tools that can expose PEMCs and shape travel risk mitigation. But it’s vital that customers, insurers and assistance providers alike are honest and transparent about what individual medical circumstances are and about what insurance cover can be provided. Because it’s in everyone’s interest that they are.