Long story short, a member of my family had to undergo a gall bladder operation whilst abroad. The insurance company is correctly saying we are only insured for emergency cover abroad. Now what actually happened is that the person in question originally wanted gallstones removed and upon entering the hospital was advised that the condition was acute i.e. inflamed gallbladder etc and that surgery was urgently required. The insurance company says that does not count as an emergency, because the procedure was elective, when it clearly wasn't strictly elective as it was done due to the acute condition of the gall bladder. So we are down to arguing about the meaning of the word emergency. They take the view that you have to be admitted as an emergency, I take the view (as per most medical dictionaries) that an emergency is something that is urgent and can affect long term health or cause death. (and a friend has just died waiting on the good old NHS for a gall bladder operation).
So, has anybody been in a similar situation with the insurer? What was the outcome? Is taking legal action likely to help or is it a lost cause?
Well, first of all, they don't remove just the stones...it's either the whole thing or nothing here in the US. Secondly, the doctor should be detailing the "emergency" to the insurance company...in other words, that this test or that symptoms meant it was about to rupture (which is the only reason it's an emergancy with gb).
The medical report revealed 'acute inflammation on top of chronic cholecystitis which confirmed the judgement of urgent surgery' I don't know if that means the gallbladder was in danger of bursting or not?
I don't either. It would seem you need to contact the doctor and ask if he could state that to the insurance company. Have you contacted the doctor with regard to this? Normally here in the US the doctor would be willing to clarify his dx in order to help get the insurance payment. I don't know whether that is normal in the country where this occured. Urgent and emergency have different meanings. Was the patient given any other option? Why did he/she decide to proceed with the surgery rather than return home for it?
The doctor offered to speak to the Health Insurance people on the phone, but I don't know if that happened or what was said.
In any event, I suspect after talking to the insurance people several times, they would say that had the gallbladder burst, that would have been an emergency. An operation to prevent it bursting is not an emergency but is elective.
If you watched the movie Sicko you would have learned that insurance companies have huge staffs including doctors whose only job is to pore over all claims and look for any excuse not to pay the claim. Any flimsy excuse will do.
Titchou: Here in the US they do just remove gall stones, at least they do at the hospital I was at. I started having gall bladder problems when I was about 30weeks pregnant. From the time my daughter was born to 2 months later I was in and out of the ER at leadt 2 dozen times. I was admitted twice, the first was for and ERCP where they removed several stones. The second was because I refused to leave until they took my gall bladder out, I had a date set for 2 weeks later. Good thing I demanded that it come out, had I of waited the 2 weeks I would have been dead from sepsis.
Nepenthes: I think emergency in insurance terms means the difference of life or death. If your family member was not going to live for a scheduled surgery, than that would qualify as an emergency. If they could wait til a scheduled surgery, than that is not an emergency. The drs and that person are going to have to get the insurance company to understand that. It is a fine line, and insurance companies are wanting to make sure that they are paying for something that is justified. There are many people who "think" they need surgery or some sort of procedure and they get it without medically needing it. That is why insurance companies want to make sure that it was a true emergency. And often the cost is a lot higher overseas, so they really don't want to pay more than they have too. I hope this helps.