Blue Cross denies Sask. man’s insurance claim after Arizona stroke

A Saskatchewan man is facing enormous medical bills after his insurer denied coverage following a stroke he suffered while in Arizona.

What happened: 72-year-old Louis Lamothe, from the town of Halbrite, was on an annual vacation in Yuma, Arizona with his wife, Arlene. They had been going there for the past 10 years.

• On the morning Feb. 3, Arlene found her husband on the floor. He had suffered a massive stroke which left him paralyzed on the left side, and was rushed to the hospital.
• Lamothe was airlifted to Banner – University Medical Center in Phoenix.
• He was intubated and remained in ICU for two weeks.
• Blue Cross denied Lamothe’s travel insurance coverage 16 days into his hospital stay.
• The family paid $56,000 up front to fly Louis to Regina General Hospital on Sunday night, through Angels of Flight Canada Inc., an Ontario company that provide medical flights.
• Lamothe has trouble walking and is now working with a speech pathologist to develop his speech and ability to swallow.

Medical Bills: Louis Lamothe faces hundreds of thousands of dollars in medical bills for various services during his stay in Arizona.

• $56,000 was paid upfront for a medical flight to Canada, which was covered by the sale of the Lamothes’ RV and contributions from granddaughter Rebecca Fee.
• Lamothe required care from six specialists.
• The hospital performed multiple CT scans, ultrasounds and X-rays each day.
• The couple will try to work out a payment plan with the Arizona hospital.
• Arlene says they are on pension, and that any additional funds to cover medical expenses will have to come from the sale of their house.
• The family has set up a GoFundMe campaign in an effort to raise money to pay for some of their expenses.

Insurance claim denied: Blue Cross denied Lamothe’s travel insurance claim around Feb. 19, refusing to pay for any of his medical bills or transportation to a Canadian hospital.

• Blue Cross argues that Louis Lamothe failed to report a change in his cholesterol medication, from a dosage of 10mg to 20mg in July 2022, three months before he left for Arizona.
• Lamothe also suffers from chronic obstructive pulmonary disease.
• The family says that Louis’ failure to disclose the change in medication wasn’t deliberate, but doesn’t know how to prove it.
• Granddaughter Rebecca Fee said that “he would not have hid a 10-milligram cholesterol dosage change. So, whether he forgot as a 72-year-old that his dosage change even happened, or that he even knew, we can’t confirm it.”

Blue Cross says: Saskatchewan Blue Cross says that their decisions undergo “a formal review with multiple stages involving both internal and external experts.”

• They “ensure plan members understand their coverage, its limitations, and the appeals process available should any new information emerge that warrants additional consideration in a claim decision.”
• “It’s equally essential to ensure that you update your travel insurer when health circumstances change,” said the insurance company.

Blue Cross reverses course

On Mar. 2, Blue Cross informed the Lamothe family that they would honour the insurance claim and cover all expenses, including medical fees, Louis’ repatriation to Alberta, transportation expenses, and a small amount of incidental expenses.

Fee told CBC News that the family can “breathe again” after the insurer’s unexpected decision.

“It’s just a huge sense of relief that Blue Cross reversed its decision. They didn’t give us a reason why they changed their minds, but I don’t need that reason as long as they cover it.”

The reversal by the insurance provider comes after insurance lawyer Sivan Tumarkin, Co-founding Partner at Samfiru Tumarkin LLP, spoke to CTV Regina about why insurance companies deny legitimate claims, how to respond when your claim is denied, and tips when purchasing insurance coverage.

‘Million dollar baby’ case

Louis Lamothe’s case is reminiscent of another Saskatchewan family’s experience with Blue Cross in 2014.

In that instance, Tumarkin helped Jennifer Huculak-Kimmel fight against Blue Cross after their travel insurance claim was denied after she gave birth prematurely to her daughter in Hawaii.

The family was left with a $1 million hospital bill after Blue Cross denied their claim due to pre-existing conditions, which Tumarkin helped them dispute.

LEARN MORE
• Rights when long-term disability denied in Saskatchewan

Travel insurance claim denied?

Tumarkin says that travel insurance policies are intended to provide “peace of mind” to individuals and their families when they go abroad.

“It’s a devastating experience when your insurance provider rejects your claim and decides to turn their back on you when you need their support the most,” says Tumarkin.

When you obtain travel insurance, it is important to read every aspect of your policy, including the fine print that concerns factors such as changes to your health or prescribed medication. Tumarkin says that if there are parts of your policy that you don’t understand, you should ask the insurance company for further explanation so you know what it is you are purchasing.

If the insurance company denies your claim for travel insurance, don’t panic, says Tumarkin.

“Your insurer’s denial letter isn’t the final word on the matter. During my years of practice, I have seen insurance companies deny travel, long-term disability and other claims for completely inappropriate reasons.”

“Their hope is that you will accept the denial at face value and not ask questions or seek legal assistance. An insurance company’s ultimate goal, after all, is to make profits. They do that by charging premiums and denying legitimate claims all the time to hold on to as much of your money as possible.”

How we can help

If your insurance claim is denied or cut off for any reason, contact the experienced insurance law team at Samfiru Tumarkin LLP.

We know the law and regularly resolve short-term disability, long-term disability, life insurance, critical illness and mortgage insurance claim denials all over Canada (excluding Quebec).

Several of our lawyers previously worked for insurers, which means we know how they operate, why they make certain decisions, and how to enforce your rights.

We have helped thousands of clients, including Julie Austin and Sandra Bullock, hold insurance companies accountable after their claims were denied or cut off prematurely.

Our insurance lawyers provide free consultations and we don’t get paid unless we secure the compensation that you are legally entitled to.