suze

Welcome to Fodor's.

IMDonehere

Travel Guard has nothing to do with health insurance. It pays for emergency medical.

I know this policy well.

Michael

Travel Guard has nothing to do with health insurance. It pays for emergency medical.


To me that looks like it's splitting hair, all to the advantage of the insurer.

Gretchen

Michael, are you really surprised by that! LOL

IMDonehere

It is not splitting hairs, insurance is highly regulated and travel insurance is an entirely different business than health insurance. For example, does health insurance give benefits for a cancelled trip?

gail

Your recourse is to file an appeal - almost everything has that as an option. Your appeal should concentrate on what you were told - details of dates, with whom you spoke, etc. If you can get your home arthropod to say your knees were fine before you left, that would help - but good luck getting that. They will take no consideration of "it's just not fair". They want facts.

And the appeal will look at the very fine print of the policy you bought. There are all kinds - and even Travel Guard has several types.

I don't see how you could win an appeal on the overage of PT - they told you $400 and you went over that by choice without further approval. That is no different than regular health insurance - there are certain things for which one needs prior approval or they don't pay. But you might get some positive resolution on MD fees.

As a rehab RN, an argument is going to be made that you have arthritic changes - documented by X-Ray in your lower extremities, and that this problem is related to hip arthritis.

Sue_xx_yy

Welcome to Fodor's.

Here's how I understand your dilemma. While on extended vacation, you had sudden severe knee pain not related to any particular event (i.e. you didn't fall down your hotel's stairs and damage your kneecap or whatever). On the other hand, you have a history of a hip x-ray.

This is a tricky one. I have had bone density scans to see if I am developing osteopenia/osteoporosis. I have not yet experienced symptoms, and the data coming back suggests that such problem as I have developed to date, is very minor. Was it the case that your hip x-ray was just a routine checkup, like my BD scans, or did you go for the x-ray because you had reported to your doctor that you were feeling pain in your hip, or elsewhere in your skeleton? If the latter, I suspect you will have a hard time pushing your claim, since as Gail's post implies, it is not unexpected for people who have developed arthritis in one area, to develop it in another area.

But if it is the former, I'm wondering if you might have a chance. Again, I'm guessing, but the key might be to show that your x-ray was just like getting a routine blood pressure check - a routine, not something done in response to a specific, pre-existing problem.

Sue_xx_yy

I would add, that even if you can show the x-ray was just a routine diagnostic test, it will still be tricky, because there doesn't seem to have been any event that you sustained while on vacation, that was the cause. Arthritis generally takes awhile to develop - sometimes years - and insurance companies know this. On the other hand, insurance companies have been known to pay for at least first line treatment for heart attacks, etc - and cardiovascular disease doesn't develop overnight, either.

indyhiker

In response to Sue, I'd note that IT band issues and arthritis are two different things. The IT band is a thick set of fibers that run from the hip to the outer knee. You can get tendonitis in the IT band just like you can in other spots of the body--often from overuse or biomechanical problems. I have hip arthritis and have had IT band issues caused by how my road bike's pedals were set up of all things; they had nothing to do with one another. Whether that's true for the OP, I don't know. Lower-body dysfunction can present in some funny and often misleading ways. You can experience pain in your knee that has to do with some form of hip dysfunction and vice versa.

How you challenge Travel Guard's decision, I don't know. The policy itself may have some information in it about challenges to claim denials. If you can get any information from your treating ortho as to his opinion (assuming it's helpful to you) as to whether the IT band issues were related to your hip issues, that may help.

IMDonehere

How to contest a claim:

1. You write to Travel Guard and provide documentation and dates, copies of any relevant medical records, and dates of phone calls and their content and any written correspondence. It should be in chronological order and be concise and precise. Do not include anything that isn't factual. Be professional and courteous.

2. If they still deny the claim, you write TG and tell them you are filing a "bad faith" claim with the Insurance Dept. in the province where you bought the policy.

3. If Travel Guard still denies the policy then you send the Insurance Dept. in the province in which you bought the policy all the facts and relevant dates. Once again be precise and concise and professional and courteous.