Will filing a complaint with DOI help if a travel health insurance company has denied claims and appeals?
Question Details: A travel health insurance company has denied a claim for medical services received during the policy period stating "Pre-existing" as the reason for denial. The medical condition was discovered for the first time at the time of diagnosis during policy period and was never identified or even had a reasonable certainty of existence prior to this diagnosis. The company has denied the claims appeal twice - first by stating that the policy was purchased after the symptoms began and when proven otherwise with the help of doctors letter, they denied the appeal for the second time stating a different reason - the policy wording, which states the definition of pre-existing condition as any condition known or unknown which had "reasonable certainty of existence" is not covered. Will filing a complaint with the DOI help, as this condition came up as a surprise and there was no clue about this till the time it was diagnosed. Hence not sure as to how reasonable certainty of existence is applicable here.
Actually, the most effective way to proceed would be to file a lawsuit against the insurer for "breach of contract": for violating the insurnace policy's (which is a contract) obligation to pay in these circumstances. If you can prove in court that under the terms of the policy as applied to the facts, they should have paid, the court can order them to pay. If it's not worth the cost and effort of a lawsuit, then it's probably not worth pursuing; you could try filng the DOI complaint, which is free, but it it is unlikely that the complaint will result in being paid.