Trip Interruption Denied/How to get it approved

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Sep 20, 2016
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#1
Trip Interruption claim and appeal denied; I feel there were extenuating circumstances to warrant pmt. The trip was to walk a pilgrimage on two different paths in Northern Spain. On Day 2, fell in bathtub injuring back. Saw physician that day, xrays = no broken bones. advice - sth for pain, should be ok in a few days. 2 days later severe muscle spasms; to ER, more xrays, no broken bones. Received 2 rx meds, told to rest 4-5 days. Helped, but could not carry or pick up 15 lb backpack. Gave up on walking 1st path, so travelled to city at beginning of 2nd hoping rest would help so I could continue. After 2 weeks of rest and pain meds, still could not pick up or carry pack; waking during night due to pain and muscle spasms. Decided to return home where I could see my own physicians, discuss all aspects of injury and prognosis in English, and within my own culture. Didn’t consider seeing another physician since already told twice no broken bones & verified by x-rays. At home, pain continued, saw physicians twice due to pain - advised gentle stretches, and walking, but not to carry pack until better, sought acupuncture 3 times, with relief after the 3rd session, 5 wks after fall.
Since I was not able to continue planned trip, due to fall, extenuating circumstances exist for pmt of claim. BUT I did not get a physicians statement to interrupt my trip, and that is specified in the ins policy. At one time insurance would look at "extenuating circumstances" and allow payment. I don't know if that exists now.
What do you think? Thanks!
Further: I submitted claim with full documentation (narrative, medical records, receipts), a month later, denied - did not obtain physicians stmt to interrupt trip. Request sent to appeal - extenuating circumstances with more detail, a month later same denial. Have just sent appeal to Claims Concierge at Seven Corners Ins. with addl detail about expected trip - pilgrimage, carrying backpack, staying in albergues / hostels.
 
Last edited:

Neil Maley

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#2
Without documentation from a doctor over there on what happened, how can the insurance company verify what happened?

In the documents you receive with insurance almost every one I have seen tells you what you need to obtain for a claim. How can a company pay out on something not documented? You could make up a story to try be repaid for your trip- they can't simply take your word for it.

I would suggest contacting your tour company to see if they can get you the name and contact information of the doctors this saw you and ask them for a letter stating what happened.

Without that you can't appeal.
 
Sep 20, 2016
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#3
When I sent the original claim, all the documentation from the two medical facilities with signatures by the doctors was also submitted along with a spreadsheet of all expenses with receipts, other than food, from the day of the fall until the final acupuncture treatment.

Within a half hour of falling I called the insurance company to report the fall (after I called the front desk at the hotel where it happened, and they came to my room). John, with whom I spoke, said I would need to see a doctor and get a statement from him — which I did.

There is no tour company. I was travelling on my own.
 

Carrie Livingston

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#4
BUT I did not get a physicians statement to interrupt my trip, and that is specified in the ins policy. At one time insurance would look at "extenuating circumstances" and allow payment. I don't know if that exists now.
What do you think? Thanks!
Further: I submitted claim with full documentation (narrative, medical records, receipts), a month later, denied - did not obtain physicians stmt to interrupt trip. Request sent to appeal - extenuating circumstances with more detail, a month later same denial. Have just sent appeal to Claims Concierge at Seven Corners Ins. with addl detail about expected trip - pilgrimage, carrying backpack, staying in albergues / hostels.
I would try and contact the doctor that treated you and see if s/he could provide something stating that based on the nature of your trip, it would impossible for you to continue. Bed rest is necessary, etc. It seems that's what they are looking for is "documentation" to prove that you were unable to continue your journey.
 
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Aug 28, 2015
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#5
Trip Interruption claim and appeal denied; I feel there were extenuating circumstances to warrant pmt. The trip was to walk a pilgrimage on two different paths in Northern Spain. On Day 2, fell in bathtub injuring back. Saw physician that day, xrays = no broken bones. advice - sth for pain, should be ok in a few days. 2 days later severe muscle spasms; to ER, more xrays, no broken bones. Received 2 rx meds, told to rest 4-5 days. Helped, but could not carry or pick up 15 lb backpack. Gave up on walking 1st path, so travelled to city at beginning of 2nd hoping rest would help so I could continue. After 2 weeks of rest and pain meds, still could not pick up or carry pack; waking during night due to pain and muscle spasms. Decided to return home where I could see my own physicians, discuss all aspects of injury and prognosis in English, and within my own culture. Didn’t consider seeing another physician since already told twice no broken bones & verified by x-rays. At home, pain continued, saw physicians twice due to pain - advised gentle stretches, and walking, but not to carry pack until better, sought acupuncture 3 times, with relief after the 3rd session, 5 wks after fall.
Since I was not able to continue planned trip, due to fall, extenuating circumstances exist for pmt of claim. BUT I did not get a physicians statement to interrupt my trip, and that is specified in the ins policy. At one time insurance would look at "extenuating circumstances" and allow payment. I don't know if that exists now.
What do you think? Thanks!
Further: I submitted claim with full documentation (narrative, medical records, receipts), a month later, denied - did not obtain physicians stmt to interrupt trip. Request sent to appeal - extenuating circumstances with more detail, a month later same denial. Have just sent appeal to Claims Concierge at Seven Corners Ins. with addl detail about expected trip - pilgrimage, carrying backpack, staying in albergues / hostels.
There are no extenuating circumstances here. Your scenario is the typical scenario that leads to a trip interruption claim. The trip interruption claims adjusters only see cases of the nature you describe and much worse. Otherwise the trip would need no interruption. Could you post a copy of your appeal denial?

Why didn't you provide the doctor's direction to interrupt the trip? That's the most important part. Also, your trip may still be consideeed interrupted if you stayed there but couldn't do the things you were there to do. Under what circumstances does your policy cover the cost of the trip? What expenses are you seeking?
 
Sep 20, 2016
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#6
I would try and contact the doctor that treated you and see if s/he could provide something stating that based on the nature of your trip, it would impossible for you to continue. Bed rest is necessary, etc. It seems that's what they are looking for is "documentation" to prove that you were unable to continue your journey.
Thanks for the suggestion, Carrie, but that first doctor - in Spain - only said I should take a pain reliever and in a few days all would be ok. Then HE would not let me pick up my pack, but carried it out to where I was waiting for a ride back to Madrid, chivalrous, but not really helpful in his assessment of the real injury.
 
Sep 20, 2016
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#7
There are no extenuating circumstances here. Your scenario is the typical scenario that leads to a trip interruption claim. The trip interruption claims adjusters only see cases of the nature you describe and much worse. Otherwise the trip would need no interruption. Could you post a copy of your appeal denial?

Why didn't you provide the doctor's direction to interrupt the trip? That's the most important part. Also, your trip may still be consideeed interrupted if you stayed there but couldn't do the things you were there to do. Under what circumstances does your policy cover the cost of the trip? What expenses are you seeking?
Re 1st paragraph: attached are both the initial denial and the appeal denial.

Re Paragraph 2: That's the problem, there is no doctor's direction to interrupt the trip - just my say-so because I could not pick up or carry my backpack due to the severe pain. Your 2nd sentence as well as the first part of your 1st paragraph encompasses my whole point. From the day of the injury, I was not able to continue with my trip as planned.
 

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Neil Maley

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#8
When I sent the original claim, all the documentation from the two medical facilities with signatures by the doctors was also submitted along with a spreadsheet of all expenses with receipts, other than food, from the day of the fall until the final acupuncture treatment.

Within a half hour of falling I called the insurance company to report the fall (after I called the front desk at the hotel where it happened, and they came to my room). John, with whom I spoke, said I would need to see a doctor and get a statement from him — which I did.

There is no tour company. I was travelling on my own.
Did the statements say they advised you to be off your feet? Or advise to cut the trip short?

Just saying you saw a doctor is not enough. The doctors statement must say you cannot travel further. I can understand the insurance company saying you continued on for 15 days.

What you will have to do to get this approved is get another letter from the Drs. Saying you were advised bed rest and then from second dr. Saying he advised you to return home.

Without that specifically stated you haven't shown you were medically advised to cancel the rest of your trip.
 
Sep 20, 2016
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#10
Thank you for helping me look more carefully at my policy and the individual coverages.
The following is how I perceive my claim.
My claim is for trip Interruption only. The medical bills have been paid by my health insurance. There was never a need for medical evacuation.
Trip interruption because I simply could not continue my trip as planned. If I had had concierge service there would have been someone to verify my condition. Staff Member and Advocate AAGK above speaks to the issue of Trip interruption coverage to a certain extent.
There is no medical statement from an attending physician at the time of the accident other than what is on the official medical documents provided to me by the Spanish medical facilities in which I received care. This omission is, in part, due to my travelling alone and not having someone to help with the legal aspects of an impending claim. Being alone was in part due to the conversation I had with John at Seven Corners (317-582-2690) at 09.56 Spanish time on 21 April, 2016. I asked about calling the concierge service at my Visa Credit Card company, and he was emphatic that I should not do that, and if I did it could jeopardize my insurance coverage. I thought at that moment that I would be medically evacuated, since I had not seen a doctor yet, and was in such severe pain. He told me I needed to see a doctor and who would request the medical evacuation. He gave me a number to call in Spain - 34 690 388 037 - I called and spoke to someone briefly. I remember making the calls, but do not remember the conversations. I remember only that I was crying by then because of pain, because of fear, and not finding anyone through the insurance company who could help me at that moment.

I am filing this claim because I bought and paid for Trip Insurance that included Trip Interruption coverage. I fully believe that I suffered an "accidental injury" as defined in Section I. General Definitions of this policy. Under Section IV. Coverages Trip Interruption - I experienced a Trip Interruption due to an Accidental Injury. And because when I called the phone number on the Insurance ID Card for medical assistance or travel assistance, I did not receive any assistance. When the Insurance ID Card indicates how to contact the insurance company "For EMERGENCY evacuation and medical assistance, or travel assistance ONLY", one should reasonably expect to find some assistance.
 

Neil Maley

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#11
Can you post a link to the actual policy so we can see what the trip interruption portion say? That would be different than what they are quoting in their letter.

If we can see the full policy we may be able to find something more specific to trip interruption, but in my experience with insurance claims, you would have needed the doctor to clearly state in the letter that you cannot continue to travel and must return home.

Let's see if we can find something else in the policy.
 
Aug 28, 2015
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#13
Did you fly home early? They aren't going to pay you for hotel nights you used and meals you ate while in Madrid. Specifically what costs did you have. Did you change your ticket, etc? Certainly you can do thinks in Madrid and leave your backpack in the room.
 
Sep 20, 2016
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#14
Did you fly home early? They aren't going to pay you for hotel nights you used and meals you ate while in Madrid. Specifically what costs did you have. Did you change your ticket, etc? Certainly you can do thinks in Madrid and leave your backpack in the room.
Yes I flew home early and had to change ticket - an extra $521.00. I haven't claimed any meals - no receipts. Thought the nights in Madrid might be paid since the Dr at the ER in Madrid said 4-5 days rest without jarring the back - 6 nights - $260.39 . I did wander Madrid - I could walk - just not able to carry or lift the pack.
 

Neil Maley

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#16
Can you post the letter the doctor gave you? Did it specifically say that he advised you to return home early or to cancel anything that you were unable to do? A claim is dependent on the doctor writing up your case properly convincing the insurance company that your health was impaired and you had to return home early because it was too dangerous for you to continue traveling in the condition you were in. Unfortunately because of the clippings you did in your document, I can't copy and paste the applicable sections from your document.

What exactly did the letter say? I have seen cases lost because of the way the letter was written by a doctor that made the condition appear not as serious as you thought it was. He had to order you to stop traveling. Did he do that?
 
Sep 20, 2016
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#17
@Helento, hopefully you are feeling better now. Does the ER report state that you needed 4-5 days bed rest? That might be the route to go if you haven't already.
Yes, I'm better now, thanks. ER report is in Spanish and is 5 pages. Two of those pages I had translated to English so my primary medical Insurance could process the claim. To answer your question - the ER report says 4-5 days rest (but it does not say bed rest) and several other directions - dry heat, two prescription drugs, see my primary care doctor in 7-10 days to monitor condition. If symptoms worsen or others arise, go to the ER.
 
Sep 20, 2016
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#18
Can you post the letter the doctor gave you? Did it specifically say that he advised you to return home early or to cancel anything that you were unable to do? A claim is dependent on the doctor writing up your case properly convincing the insurance company that your health was impaired and you had to return home early because it was too dangerous for you to continue traveling in the condition you were in. Unfortunately because of the clippings you did in your document, I can't copy and paste the applicable sections from your document.

What exactly did the letter say? I have seen cases lost because of the way the letter was written by a doctor that made the condition appear not as serious as you thought it was. He had to order you to stop traveling. Did he do that?
Neil, there is no letter from the doctor, I only have the Emergency Room Discharge Summary - the original Spanish and what I had translated to English - would you like both? It mentions Current Ailment, the Physical Exam, Complementary tests, Diagnosis, and Treatment which says: "Rest for the next 4-5 days, [but does not say bed rest], avoiding quick movements and big efforts, Dry heat over the affected area for 20 minutes 3 times a day, NOLOTIL 575 mg every 8 hours, ROBAXISAL COMPUESTO: tablet 380/300 mg every 8 hours for 5-7 days [he then drew a diagram for me and explained slowly in Spanish how to take the two drugs - NOLOTIL breakfast, lunch and dinner and ROBAXISAL BETWEEN the NOLOTIL - these directions, of course, are referring to Spanish mealtimes - not American ones, which are quite different], go to your primary care doctor in 7-10 days to monitor condition. If symptoms worsen or others arise, go to the ER."
NOTE: IF I had understood better his reference to seeing my doctor in 7 - 10 days, or IF I had had someone with me to assist and discuss what and how it was phrased, I might have asked more questions to get a more precise understanding. The Spanish - and European - systems are not focused on legalities as in the US, it's a cultural and medical difference that puts Americans in a very difficult situation in cases like this. This Spanish doctor was giving me information from his Spanish perspective, not from my American one! Of course you've "seen cases lost because of the way the letter was written by a doctor that made the condition appear not as serious as you thought it was." But why should we (patients and claimants) be denied benefits because of these differences?
 

Carrie Livingston

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#19
@Helento , did you happen to see your primary care doctor in that 7-10 day time frame? Oh, on further re-reading see that you stayed in Spain for about another 2 weeks trying to recover and then flew back home and saw your regular doctor. I wonder if a statement from your regular doctor about the fact that you still weren't well and would have been unable to continue would be helpful?
 

Neil Maley

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#20
Here is the problem- the letter does not state you were too sick to continue your trip and that you needed to get home. That is why they aren't covering you.

For trip interruption to be considered the doctors report must state that you have to cut your trip and rerun home as a medically necessity. And it doesn't.

That is specified in the t and c but I can't copy and paste it because you have done some kind of highlighting on the copy that doesn't allow me to copy it.

I have had a lot of experience with claims and as I said before, a claim is dependent on exactly what the doctors report states. They did not say it was medically necessary to cut your trip short and return home immediately.