A misunderstanding in the medical report jeopardised the coverage of an expensive surgery for a client with health insurance. Still, thanks to our fast and efficient management, the insurer approved the operation in less than 24 hours—a success story.
Recently, one of our health insurance clients contacted us about an urgent situation while we were travelling outside Europe. The client had suffered an accident while performing his regular workout at the gym. During the exercise, he twisted his foot, resulting in a significant injury that required immediate medical attention. Upon arrival at the emergency room, the medical team determined that this was a complex injury requiring urgent surgery. Working out at the gym,.[/] Since this kind of intervention is expensive – in this case, the cost exceeded €10,000 – the hospital requested authorisation from the insurance company. Still, to the client’s surprise, the company refused coverage even though the client had taken out health insurance. The reason for the refusal was that the documentation submitted indicated that the accident occurred during the practice of a sport that the insurer classifies as risky, and therefore excludes from the coverage of its policy.
Faced with this situation, the client contacted us to understand the insurer’s rejection and how to proceed. After receiving all the documentation, we noted that there was a misunderstanding in the medical report’s description of the accident, which led to confusion about the type of activity the client was performing. The doctor had interpreted the exercise as a high-risk sport, which led the insurer to apply the high-risk sports exclusion.
Rapid intervention and resolution
We contacted the doctor who had written the report to clarify the facts and rectify the information. We explained to the insurance company that this was a routine training session in a gym, not a high-risk sport. Thanks to our intervention and proper review of the documents, we got the insurer to revise their decision. In less than 24 hours, we got the green light for the surgery, allowing the client to receive the necessary medical care with all expenses covered by his health insurance with AXA.
Key lessons for policyholders
This case highlights the importance of medical reports accurately reflecting the nature of accidents. A slight misunderstanding in communication, especially in emergencies or when there are language barriers, can lead to confusion, resulting in coverage denial. It also underlines the need for professionals like the Dylsi team to manage and mediate such situations to ensure that clients receive the care they need without complications.
It is essential that policyholders are fully aware of the exclusions in their policy, such as the exclusion of high-risk sports. In this case, the intervention was covered because it was an accident during regular training, but high-risk sports, such as martial arts or extreme activities, are not covered by AXA. Understanding these exclusions can empower policyholders to make informed decisions about their activities and coverage.
This case demonstrates the value of having a dedicated support team that can quickly and efficiently manage any incident that arises with the insurance company, protecting the health and wellbeing of our customers when they need it most. At Dylsi, AXA’s exclusive agency, we are committed to being there for you, providing the support and care you need in navigating the complexities of insurance coverage.