Follow Along with me and we'll see how this claim works out

[klfrodo]

Land vacation in Cancun at a RIU Resort

The reservation included Covid Testing and  RIU Protect provided by Healix Spain.

Theoritically, the medical is "Up to 30,000 Euros per Guest"  We'll see what happens.

 

My wife was exiting a city bus, when she tripped and fell.

After being seen by the RIU lifeguard, and the RIU contracted on site physician, we were advised to jump in a cab and go to the hospital.

 

Once at the ER, she received 10 stitches and a splint for her broken left wrist.

(Note: prior to any services being performed at the hospital, a $3800 USD deposit was required) 

The services were exceptional from the reception, to the nurses, and the Dr's.

 

Received all the documents, treatment notes, and a line item break down of all charges.

 

Will be filling out paperwork tomorrow and submitting.

 

Please feel free to ask questions and/or follow along and we'll see how this goes. (Especially since we're dealing with a Spanish (Spain) company.

 

 

Normally, I use Steve at TripInsuranceStore. This time I just went with what the resort was offering at no additional charge.

[iamtrustworthy]

12 hours ago, klfrodo said:

Normally, I use Steve at TripInsuranceStore. This time I just went with what the resort was offering at no additional charge.

Hi klfrodo,

 

I hope your wife recovers quickly!

If you need any help with your claim, call or email me.

 

Steve

[klfrodo]

49 minutes ago, iamtrustworthy said:

Hi klfrodo,

 

I hope your wife recovers quickly!

If you need any help with your claim, call or email me.

 

Steve

Thanks Steve 🙂

[klfrodo]

I think I just ran across my first challenge. Have further research to do, but after reviewing the Healix-Spain claim form, they want to know who my Primary Health Care Insurance provider is. 

 

I forgot all about the Primary/Secondary coverage situation.

 

I'm sure I'm going to have to "First" file for reimbursement from my BC/BS of Alabama people.

[klfrodo]

Medicare Claim Form CMS-14905 completed today on 11 April 2021.

Will express mail claim form and supporting documents tomorrow.

 

I did add a note that we do expect this claim to be denied since service was performed outside of the US. Explained that we do need a formal denial letter prior to sending in the claim to our travel insurance provider.

[klfrodo]

15 Apr 

According to USPS tracking number, the Medicare claim form was delivered to the claim center for Washington in Fargo, ND

[klfrodo]

30 April

 

Received our Denial of benefits letter from Medicare.

 

Steve, If you're listening.... Medicare is our Primary. We do have BC/BS as secondary with an international rider. For this trip in which the injury occurred, we also had Healix Spain coverage which was included by RIU.

 

Is my next step BC/BS or direct to Healix?

 

Thanks

[iamtrustworthy]

59 minutes ago, klfrodo said:

30 April

 

Received our Denial of benefits letter from Medicare.

 

Steve, If you're listening.... Medicare is our Primary. We do have BC/BS as secondary with an international rider. For this trip in which the injury occurred, we also had Healix Spain coverage which was included by RIU.

 

Is my next step BC/BS or direct to Healix?

 

Thanks

Submit the claim to Healix and include a copy of the Medicare denial letter.

[klfrodo]

4 minutes ago, iamtrustworthy said:

Submit the claim to Healix and include a copy of the Medicare denial letter.

Thanks for your quick response.

[klfrodo]

30 April

 

Completed documentation and submitted to Healix-Spain for reimbursement

[klfrodo]

30 April

 

Healix is fast...  Already received an e-mail

 

"Please note,  RIU protect is a travel insurance that covers you for urgent medical assistance while you are staying at the hotel, it is valid from the time of check-in until check-out,

 

We regret to inform you that  we do not cover any assistance that has not been previously notified to us. As I can see in our system, we have only been contacted to request the doctor Hotel visit and we have no record for the ER care in Hospiten Cancun so, unfortunately we cannot proceed with the reimbursement.

 

Should you have any more concerns about this, please do not hesitate to contac us."

 

Sent a reply that it was RIU's own in house doctor that initiated treatment and then recommended we go to the hospital. Even supplied his notes from the initial assessment.

 

We'll see what happens        

[klfrodo]

1 May

 

I found one of the "Gottcha" moments in a travel insurance scheme.  It appears that in the excited moment when your loved one is in pain, crying, emotionally unstable, scared,,,,, someone is supposed to be able to remember to call the medical insurance people and ask permission to go to the hospital. Even though their (RIU/Healix) doctor tells you to go to the hospital for further treatment.

 

Here is their e-mail explanation.

 

"Please notice our records show we were contacted by your part requesting the doctor's visit at the hotel on the 05th of April. We don't have any records of inforrmation requesting authorisation for a hospital's visit.

 

Every medical care needs to be arranged and approved directly by RIU Protect in order to have full coverage. In this case, the doctor's visit at the hotel on the 05th of April was fully covered by us, however the hospital's visit was not informed to us in advance and therefore coverage has been rejected.

 

Sorry for the inconvenience."

 

However, I'm trying 1 last time.

Healix is referring to a doctors visit on April 5th at our hotel.

What they seem to be missing is that the incident in question was on April 4th. 

After the fall, we went to the closest RIU Hotel and requested help. THEY called their doctor. He visited, assessed the patient, and HE recommended that we go to the hospital for further treatment.

[klfrodo]

1 May

 

Props to Healix-Spain. They are quick on the denial and e-mail response.

Here is their latest.

(I will now turn to my BC/BS plan. I should be able to get "some" relief. Minus deductible, minus out of Network, minus etc) 😲

 

"Please notice that it is not our doctor, as I explained to you the assistance should have been requested directly to RIU Protect either by phone or by email for the costs to be covered.

 

Since this was not notified nor arranged by us, then the costs cannot be covered from our side.

 

Please notice this is explained in the policy details exclusions you received at the moment you made your reservation with RIU."

 

[klfrodo]

Steve,

Please feel free to comment on my experience thus far.

I'm sure their are lessons to be learned.

[6rugrats]

Sorry about this.  I would say not to rely on this bundled coverage and purchase your own travel insurance separately.  It's hard enough to deal with a company in the US, let alone one in another country.  Have you tried contacting the WA State Office of the Insurance Commissioner?  If you purchased this trip while in WA, could they require this company to be licensed in your state, and have to follow state requirements?  When I lived in WA, I found them to be very helpful.  Why not send them an email?

Edited May 1, 2021 by 6rugrats

[klfrodo]

49 minutes ago, 6rugrats said:

Sorry about this.  I would say not to rely on this bundled coverage and purchase your own travel insurance separately.  It's hard enough to deal with a company in the US, let alone one in another country.  Have you tried contacting the WA State Office of the Insurance Commissioner?  If you purchased this trip while in WA, could they require this company to be licensed in your state, and have to follow state requirements?  When I lived in WA, I found them to be very helpful.  Why not send them an email?

Thanks for the ideas. They are valid ideas.

However, this policy was not "purchased". It was provided free of charge with the booking of the stay at RIU in Cancun. It was called RIUProtect and managed by Healix-Spain.

 

Hind sight being 20/20, Yes, I would have been better off spending $70 for a coverage thru Steve with TravelSafe being the "primary" and Steve available to go to bat for me if need be.  (However,,,,) Would I have run into the same problem if I had not notified TravelSafe prior to going to the hospital. Would they have used this as a Gottcha moment to deny any claim?

Edited May 1, 2021 by klfrodo

[klfrodo]

1 May

 

Blue Cross / Blue Shield International Claim Form submitted

[6rugrats]

I think insurance laws apply whether the policy was purchased or not.  
I went to RIU Protect’s webpage and read through the first page which answers basic questions.  It does state you must call before receiving services.   But, this notification does not have to come from you.  She was seen by an RIU physician at the hotel that advised her to go to the hospital.  They should have called RIU Protect at that point.  I guess it just depends how much time and energy you want to spend on this.

It’s a good reminder for others to read their policies, because this isn’t the only one that requires notification before seeking treatment.

Edited May 2, 2021 by 6rugrats

[klfrodo]

2 hours ago, 6rugrats said:

I think insurance laws apply whether the policy was purchased or not.  
I went to RIU Protect’s webpage and read through the first page which answers basic questions.  It does state you must call before receiving services.   But, this notification does not have to come from you.  She was seen by an RIU physician at the hotel that advised her to go to the hospital.  They should have called RIU Protect at that point.  I guess it just depends how much time and energy you want to spend on this.

It’s a good reminder for others to read their policies, because this isn’t the only one that requires notification before seeking treatment.

Ill send an email to the Insurance Commission and see what they have to say about RIU Protect. Will let you know.

 

2 May

Complaint filed with Washington State Office of the Insurance Commissioner

Edited May 2, 2021 by klfrodo

[6rugrats]

Good luck.  I had a problem in WA state when I had an emergency room visit with a hospital that was  in my network.  Unfortunately, all the ER doctors were part of a group that was not contracted with my plan and there was no notification about this.  I found out when I was "balance billed" for the very large portion not covered because they were out-of-network.  I contacted the Insurance Commission and they were very helpful.  I ended up not having to pay the balance.  As of Jan 1, 2020, WA state does not allow this practice anymore.  Hopefully, they will help you.  Keep posting!

[iamtrustworthy]

Hi klfrodo,

 

I'm sorry to hear how it turned out with RIU. Unfortunately, the pre-certification requirement is common with many travel medical plans. It's one of the reasons I've resisted expanding into travel medical plans.

 

However, thanks to Covid, I'm now venturing into travel medical plans beyond the Geo Blue plans since thee's more demand.

 

Steve Dasseos

[Jersey42]

@klfrodo  This has to be very frustrating, especially for someone who probably understands more about travel insurance than 99% of typical travelers. It is the "gotchas" that one only understands if you know the plan details inside and out.  Few people do, plus who is thinking about the insurance requirements when you are injured and need medical care, especially when the insurance company referred you to a doctor.

 

@iamtrustworthy Does GeoBlue Trekker require any pre certification before getting medical treatment?  I know they have (or used to have) a 60 day notification requirement after an incident.  

[klfrodo]

23 hours ago, iamtrustworthy said:

Hi klfrodo,

 

I'm sorry to hear how it turned out with RIU. Unfortunately, the pre-certification requirement is common with many travel medical plans. It's one of the reasons I've resisted expanding into travel medical plans.

 

However, thanks to Covid, I'm now venturing into travel medical plans beyond the Geo Blue plans since thee's more demand.

 

Steve Dasseos

Steve,

Thanks for being willing to help and share information.

 

For my benefit and others, I currently have a TravelSafe Classic Policy for Washington State residents for an upcoming trip in July.

I'm looking thru the 28 page "Summary of Benefits". I can't seem to find any wording or disclaimer that indicates that I would be required to contact TravelSafe and seek permission to receive medical treatment to ensure coverage/reimbursement.

Am I missing something? If so, could you please direct me to the appropriate language?

[klfrodo]

Update on 4 May

 

Letter sent to Healix-Spain from the Insurance Commissioner of Washington State. (with some minor redaction of personal information).

 

"May 04, 2021 Healix-Spain Suite 200, 99 Derby Street Hingham, MA 02043 OIC   

 Dear Compliance Department: Enclosed is a copy of a complaint we received from (Redaction) regarding their claim denial because they didn't obtain prior approval before receiving medical treatment at nearest hospital. Please review your policy and/or claim file and respond to the issues raised in the complaint. Your complete response should include: All documentation supporting your position. Do not send film, recordings, or your entire file. The name and NAIC number of the issuing company and the specific type of contract involved in this complaint. We'll use this verification to report complaint data to the NAIC. Whether the plan is a Qualified Health Plan purchased through the Washington Health Insurance Exchange, the plan name and applicable metal level. Please be aware that your responses regarding the complaint are shared with the complainant. In addition, information provided to this office is subject to the state Public Records Act, RCW 42.56 (http://apps.leg.wa.gov/rcw/default.aspx?cite=42.56). We cannot honor carrier requests for confidentiality, non-disclosure or destruction of records in our possession unless specifically allowed under the law. WAC 284-30-360 and WAC 284-30-650 require you to provide a response within 15 business days of receiving this letter using the Commissioner's electronic company complaint response system. We expect your answer by May 31, 2021."

 

Not sure how this will go in the future but it feels good to see someone fighting along side of me.

Edited May 4, 2021 by klfrodo

[iamtrustworthy]

On 5/3/2021 at 3:01 PM, klfrodo said:

Steve,

Thanks for being willing to help and share information.

 

For my benefit and others, I currently have a TravelSafe Classic Policy for Washington State residents for an upcoming trip in July.

I'm looking thru the 28 page "Summary of Benefits". I can't seem to find any wording or disclaimer that indicates that I would be required to contact TravelSafe and seek permission to receive medical treatment to ensure coverage/reimbursement.

Am I missing something? If so, could you please direct me to the appropriate language?

Hi klfrodo,

 

You can't find it because TravelSafe (nor any of my Trip Cancellation plans) doesn't have a pre-certification requirement.

 

Steve