What Is It?
Travel medical insurance pays for emergency medical care when you become ill or injured while travelling outside your province or country. However, a standard exclusion in virtually all travel insurance policies is the pre-existing condition exclusion — a clause that denies coverage for claims arising from a medical condition you had before the trip.
The problem: insurers interpret “pre-existing condition” broadly and “stability” narrowly, resulting in frequent denials of legitimate claims. Understanding exactly what these terms mean legally — and how to challenge incorrect interpretations — can recover thousands of dollars in denied claims.
How “Pre-Existing Condition” Is Legally Defined
Most Canadian travel insurance policies define a pre-existing condition as any illness, injury, or medical condition that existed at the time the policy was purchased. The critical limitation is the stability clause: coverage applies only if the condition has been stable for a defined look-back period (typically 90, 180, or 365 days before departure, depending on the policy).
Stable typically means:
- No new symptoms or diagnosis
- No change in prescribed medications (including dosage changes)
- No referrals to specialists
- No tests ordered or results pending
- No hospitalizations or emergency room visits
Where disputes arise: Insurers frequently deny claims by arguing that a routine medication change, a scheduled follow-up appointment, or a slightly abnormal lab result during the stability period made the condition “unstable” — even if the treating physician considered the condition well-controlled.
Your Rights to Dispute a Denial
Step 1 — Request the denial in writing. Ask for the specific policy exclusion applied, the exact basis for the decision, and all information the insurer relied upon (including any medical records reviewed).
Step 2 — Review the stability definition precisely. Compare the insurer’s characterization of your medical history against the exact wording of the policy’s stability clause. Pay attention to whether the policy requires stability of the condition or stability of treatment — these are different.
Step 3 — Obtain a letter from your physician. Your treating physician can document that the condition was clinically stable during the look-back period and that any medication or treatment changes were routine maintenance, not responses to a worsening condition.
Step 4 — File an internal appeal. All Canadian insurers must have a formal internal dispute resolution process. Submit your appeal with your physician’s letter and a written analysis of the stability definition.
Step 5 — Escalate to external review. If the internal appeal fails:
- General Insurance OmbudService (GIO): For disputes with most Canadian property and casualty insurers (including many travel insurers)
- OmbudService for Life & Health Insurance (OLHI): For disputes with life and health insurers
- Provincial regulator complaint: FSRA (Ontario), BCFSA (BC), AMF (Quebec)
What Most People Don’t Know
- A dosage change alone can void stability — even if therapeutic. If your doctor adjusted your blood pressure medication within the stability period (even to improve control), the insurer may argue the condition was not stable. Review the exact definition — some policies only void stability for dosage increases, not decreases.
- Unrelated conditions can be dragged in. Insurers sometimes argue that a seemingly unrelated condition contributed to the emergency. Dispute this — the causal connection must be clearly established; a speculative connection is insufficient.
- The GIO and OLHI dispute processes are free. You do not need a lawyer to access external review. These services provide binding or persuasive decisions and have ruled against insurers in many stability clause disputes.
- Ontario and several provinces have regulations governing claim denial practices. Insurers must have a reasonable basis for denying claims; arbitrary or pretextual denials violate insurance regulations and can be escalated to the provincial regulator.
Frequently Asked Questions
My doctor changed my prescription from one medication to a similar one 60 days before my trip. Does that void my stability?
Possibly — most stability clauses define a change in medication as a change in kind, dose, or frequency. Switching from one drug to a therapeutically equivalent drug is often treated as a change. However, your physician may be able to document that this was not related to a worsening of the condition, which can be a basis for appeal.
The insurer says they need my complete medical file from the past 2 years. Do I have to provide this?
You must cooperate with the insurer’s reasonable investigation, but you have the right to review what information is used and to challenge inaccuracies. Providing a complete medical file does not mean accepting the insurer’s interpretation of it. Consider having your physician prepare a summary statement about your stability rather than providing raw records without context.
My claim was for $35,000. Is it worth fighting?
Yes — for claims of this size, professional help (a public adjuster, insurance lawyer, or licensed representative) on a contingency basis may be available. Many travel insurance disputes are won on appeal due to insurer overreach on stability definitions. The GIO process is free and relatively quick.
What if I didn’t disclose a condition when I bought the policy?
Non-disclosure of a material fact (a condition you knew about and didn’t disclose) is a separate issue from the pre-existing condition stability clause. If you failed to disclose a condition, the insurer may void the entire policy, not just deny the claim. Disclosure obligations are taken seriously; always answer medical questions on travel insurance applications accurately.