Denied coverage by insurance company

| 16/03/2016

I have been diagnosed with a chronic disease and my insurance company has denied my claim for coverage of my related medical expenses. What can I do?

Auntie’s answer: Since this is already the second insurance question I have received, I can see this will be an ongoing issue for many readers, and understandably so. Insurance coverage might be straightforward for people who rarely get sick, but for those with real health issues, navigating through the system can be confusing and stressful.

Having said that, I feel I must emphasise that I am neither a legal nor insurance expert, so my answer can really only deal in generalities. But, unfortunately, I do have a lot of experience in dealing with insurance matters and uncooperative carriers, and do feel comfortable talking about your problem from that perspective. Plus, I will be able to point you in the right direction to seek further help.

One thing I am fairly certain about with your situation, though, is that if you have developed a chronic disease after being insured, the company should not be able to deny your claim for coverage. There are two notable exceptions: If you deliberately withheld information on your condition when first applying to be insured with the carrier or if you are trying to upgrade your policy after the fact. Your insurer can, however, raise your premium when it comes up for renewal to reflect your increased claims.

This seems like a good time to bring up pre-existing conditions as well. A very important point of Cayman’s Health Insurance Law that many people probably do not know about is that if you have been insured with one carrier for at least 12 months and were covered, for example, for a chronic or long-term illness, then if you switch to another carrier they cannot legally exclude that as a pre-existing condition. Your coverage for that illness should continue with the new company; that is the beauty of portability being written into the law.

But, a potential new insurer can deny your application for a policy and also offer you much-higher rates than with your current carrier.

I suggest you take a look through the Health Insurance Commission (HIC) website (found under the Department of Health Regulatory Services; tel: 946-2084) for more detailed information.

In addition, here is a link to the complete Health Insurance Law.

And here is my previous answer to an insurance question: Finding health insurance without a job

One other piece of advice: please do not give up if you are told no by your insurer. I have found that the first answer is often no, even though you might be standing on legally solid ground for your claim. I think that many (I cannot attest to all) insurance companies count on people not arguing their decision or taking a complaint to the HIC. Make the extra calls and demand answers from the company about the exact reasons you are being denied. Talk to the HIC if you need to. All the work will be worth it if you can compel coverage for your illness. Good luck.


Category: Ask Auntie

Comments (1)

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  1. Anonymous says:

    The individual may speak to the Health Insurance Commission however, it is more effective to put their concerns/complaints in writing.