Why Do Insurance Companies Not Pay Claims?

International health insurance gives expats peace of mind that they’ll always have access to the best medical attention while living abroad. But, what happens when you need to make a claim? Are you covered? And will your insurance pay out?

In this article we’ll explore the different types of health insurance claims to help you understand the few reasons why your health insurance doesn’t pay claims, and advise on how to find the best health insurance policy to help you avoid unpaid claims.

Why do insurance companies not pay claims?

Health insurance claims can range from routine check-ups to major surgeries and hospitalisations, with different types of health insurance policy giving different levels of cover.

That’s not to say everything is covered. Depending on the level of coverage you take out, the parts of the world included in your plan and the exclusions that apply, there may be certain things you won’t be able to claim for.

Still, at William Russell, we settle hundreds of thousands of health insurance claims each year, with the majority of claims settled in just five working days. That said, there are a few valid reasons why we wouldn’t pay a claim.

What counts as a health insurance claim?

A health insurance claim is a request you make to your insurance company to recoup the money you have spent, or been invoiced, for your medical expenses.

After getting medical treatment abroad (especially in countries that don’t offer universal healthcare to expats and digital nomads), you’ll be sent a bill. With international health insurance, you can send this bill directly to your insurer. Your insurance company will review the claim to see if your treatment is covered by your policy and, once approved, will either pay the invoice directly, or reimburse you for anything you’ve already paid.

For serious treatment where you’re admitted to a hospital, William Russell usually deals with the hospital directly to arrange your treatment and settle the bill.

Lots of people think making claims on their health insurance will be a difficult process – but really, it should be the opposite. Thousands of people make successful health insurance claims every year, as shown here:

Volume of health insurance claims paid in selected European countries in 2019

*Statista Survey Data, collated August 2021

Types of claims in health insurance

Knowing the different types of claim in health insurance can help you understand your policy inclusions and exclusions better, and save you from any nasty surprises when it comes time to claim back on your insurance.

These are the main types of health insurance claim that may or may not be included in your current policy:

1/ In-patient claims

When you are admitted to hospital overnight or for a prolonged period of treatment, you are what is known as an in-patient. In-patient care is one of the most expensive insurance policy claims, as in-patients can be charged for everything from the cost of their bed and food, to tests, treatments and surgeries they undergo, plus the costs of nursing care and equipment.

Examples of in-patient treatments might include:

• being taken into hospital after a traumatic injury
• an illness that requires ongoing treatment and supervision
• surgery
• childbirth

2/ Out-patient claims

If you’re treated as an out-patient, this means you can receive medical treatment without being admitted to hospital overnight. Out-patient claims can cover a wide variety of treatments, including expenses for GP visits and medical consultations, diagnostic tests such as blood tests or screenings, physical therapy, and small medical procedures that don’t require overnight supervision from a medical professional.

Out-patient claims are usually less expensive than in-patient claims because they involve shorter visits and less intensive treatment, with most of your recovery happening unsupervised.

3/ Prescription claims

Some health insurance policies will let you claim back for the cost of prescription drugs prescribed by a doctor. This can include over-the-counter and prescription drugs, as well as medical devices such as insulin pumps or inhalers.

Prescription claims can be expensive for expats living abroad, especially if you need long-term medication or specialty drugs that aren’t readily available in pharmacies.

At William Russell, we’re making getting your prescriptions abroad easier than ever. For our customers in the UAE, we’ve introduced Telemedicine with TruDoc, which offers 24/7 access to doctors, psychologists and well-being experts via video call, audio or live chat. With TruDoc, you’ll be able to renew your ongoing prescriptions and organise delivery as and when you need it.

4/ Planned surgery claims

Planned surgery is when you have a surgical procedure that was scheduled in advance, rather than emergency surgeries that are done in response to an immediate medical need.

Some common examples of planned surgery claims may include:

• joint replacement surgery (such as a hip or knee replacement)
• hernia repair
• cataract surgery
• gallbladder removal surgery

Health insurance claims for planned surgery could include expenses for the surgery itself, as well as pre- and post-operative care, and can be made on both in-patient and out-patient procedures.

Planned surgery claims can be particularly costly abroad, especially if the procedure is complex or requires a long hospital stay after the op.

To get an idea of how the cost of planned surgery varies across the world, here’s an overview of hip replacement costs by country in 14 selected countries:

*Data collated by World Population Review, 2023

5/ Emergency claims

As the name suggests, an emergency health insurance claim is when you claim back the expenses incurred by an unexpected medical emergency. This is when you need immediate medical attention for a serious illness or injury, rather than being referred by a doctor.

In the event of a medical emergency, emergency health insurance policies should provide cover for:

• Emergency room visits – if you’re having a sudden medical crisis, such as a heart attack, stroke, or severe injury, you may need to go to the local emergency room for treatment. Many countries do not have public health systems, meaning emergency room visits are often very expensive. Emergency health insurance claims help cover the costs of any emergency treatment, giving you peace of mind that you’ll always have access to the medical care you need.
• Ambulance services – if you find yourself in an emergency that requires an ambulance to take you to hospital, emergency health insurance will be able to foot the bill. Ambulance services can be costly, especially if you live in a country that doesn’t offer public healthcare, so it’s always a good idea to make sure this is covered in your policy.
• Emergency surgery – if after going to the emergency room, or being transported to hospital by an ambulance it’s decided that you need emergency surgery, an emergency health insurance claim will help you cover the cost of the procedure.
• Hospitalisation – if you’re admitted to the hospital after a medical emergency, an emergency health insurance claim can help pay for the costs associated with your stay, including room and board, medical tests, and medications.

6/ Mental health claims

Living in a foreign country can be tough. As an expat living abroad, it’s important not to neglect your mental health. However, the cost of mental health care can be expensive, especially if you need ongoing support.

If you have mental health insurance cover included in your policy, you’ll be able to make mental health claims relating to medical conditions such as depression, anxiety, or addiction. This includes covering the cost of any ongoing therapy, counselling and medication.

7/ Rehabilitation claims

If you’ve undergone invasive surgery or have suffered a serious physical injury, you may need ongoing physical or occupational therapy to regain your strength and mobility after leaving hospital – this is called rehabilitation.

Rehabilitation claims can help pay for any physical therapy, counselling or medical equipment such as prosthetics, crutches or wheelchairs to help you on your way to a full recovery.

Reasons why your insurer wouldn’t pay a health insurance claim

There are a few common reasons why your health insurer may be unable to support your claim. These reasons include:

1. Your plan doesn’t cover your treatment – This can often be the case in situations where you have not included optional levels of cover. For example, if your health insurance plan doesn’t include dental care, we won’t be able to cover a claim for this form of treatment.
2. You didn’t pre-authorise your treatment – There’s no need to pre-authorise small things like GP visits or prescriptions. But if you see a specialist for cancer treatment and are admitted to hospital for treatment, you’ll need to let your health insurer know before you undergo treatment. This could even be a huge benefit to you, as your insurer may be able to point towards top-quality treatment in specialist treatment centres.
3. Accidents/injuries as a result of not following local motoring laws – Driving laws vary all over the world. Make sure you know the rules of the road before getting behind the wheel, otherwise you may not be covered by health insurance should something go wrong.
4. Alcohol or drugs – If you’re in an accident while under the influence of drugs or alcohol, your insurance policy may not be able to cover you.
5. Experimental drugs and treatments – Your insurer may not be able to cover the costs of any treatment that hasn’t been officially approved by the medical boards in your country.
6. Pre-existing medical conditions – If you have a pre-existing medical condition that your insurer has not explicitly agreed to cover under the terms of your policy, they won’t be able to pay health insurance claims related to that condition.
7. Wilful exposure to needless danger – While this is a rarer form of exclusion, you will encounter it if you injure yourself while taking part in reckless pursuits in unregulated and unmarshalled environments – for instance, skiing off-piste.
8. Treatment by a family member or by a hospital in which you have a professional or financial interest

William Russell’s approach to claims

At William Russell, we go the extra mile to make sure our members get a fair resolution to their claims.

Whereas other insurers may scrutinise claims looking for reasons not to pay, we take every claim at face value. We trust our members to be honest in their claim applications, and do everything in our power to help them.

This starts with making sure our members understand their policies, what they can claim against, and that they know how to make a claim. Our policy wording is easy-to-read, and our award-winning customer service team are on-hand to help you make sense of your entitlements.

You can make a claim online using our easy-to-access portal, and we aim to process all claims within five working days. Once your claim is authorised, we take care of all the paperwork, paying the medical supplier directly, giving you total peace of mind.

At the end of the day, we want to be sure that our members feel secure choosing insurance through William Russell. Where other insurance firms try to find a way to wriggle out, we’ll try to find the best resolution for you.

How to choose the right health insurance policy for you

International health insurance is an important consideration for anyone who is living or travelling abroad. It is essential to choose the right plan to ensure that you have access to quality medical care and protection from unexpected medical expenses.

Here are some of the key factors to consider when selecting an international health insurance plan, to make sure you always have the level of cover you need:

1/ Personal needs and budget

When selecting an international health insurance plan, it is important to consider your personal needs and budget. Take into account factors such as age, pre-existing medical conditions, and any additional extras such as dental cover that you may need while living abroad.

2/ Global coverage

Look for insurance plans that offer 24/7 customer support and global coverage to ensure you are connected to your insurer at all times and in all places. This is particularly important if you travel frequently or live in multiple countries.

3/ Disclose pre-existing medical conditions

It is important to disclose any pre-existing medical conditions to the insurer when applying for coverage to ensure that you are fully covered. Failure to do so may result in your claim being denied.

4/ Level of customer service and claims support

Choose an insurer with a proven level of customer service and claims support to ensure you can get help when you need it. Look for insurers that offer 24/7 customer support and online claims submissions for fast claims processing times.

5/ Understand the terms and conditions

Make sure you understand the terms and conditions of your policy before signing up to ensure you know of any limitations or restrictions. You should also be mindful of the length of coverage and coverage limits.

6/ Comparison

Compare different plans and insurance providers to determine which one best suits your needs. Consider the coverage limits, deductibles, and exclusions of each plan, as well as any additional benefits and services offered.

7/ Review coverage regularly

Review your insurance coverage regularly and make changes as needed to ensure that your plan continues to meet your needs. This is particularly important if your personal situation changes, such as if you develop a new medical condition or if you move to a new location.

8/ Know who your insurer is – and vet them

Some insurance companies act as brokerages, meaning your policy will be underwritten by another, often much larger firm. This isn’t necessarily a bad thing, but you should look into the firm behind your insurer. Whoever your insurer is, make sure they are a stable organisation, based in a country with a secure financial sector, and regulated by a reputable regulator.

Need more help choosing the right international health insurance plan?

At William Russell, we have over 30 years’ experience providing international health insurance to expats just like you, in over 150 countries worldwide.

Choosing the right international health insurance plan is an important step when starting a new life as an expat. If after reading this guide, you still don’t feel confident choosing the right plan to cover all your medical needs, don’t hesitate to contact us today – we’ll be happy to help.