Monday, January 07, 2008

Rejection of medical claim - congenital condition

Dear Mr. Tan,

I have taken medical insurance for my daughter since she was a baby. There was no claim for more than 10 years.

Recently, we discovered that she was suffering from a serious medical condition. The insurance company X rejected the claim as the medical condition was congenital. We feel that this is most unfair. What is your advice?


I suggest that you bring this this matter up to the senior management of X. You can point out that this illness was discovered more than 10 years after the policy was taken up. Due to the long lapse of time, it may not be fair for them to apply the congenital clause.

Perhaps you can ask them to get their doctor to certify that the illness is really congenital and should be excluded.

If they do not give you a satisfactory explanation, you can lodge a complaint with the Financial Dispute Resolution Center:

I wish to extend my sympathies on your predicament, first on this unexpected illness and second on the rejection of the claim. I hope that the senior management of X will take a sympathetic view. I wish you all the best.


Anonymous said...

You should sue the company or make public your predicament to give the company a bad publicity.
There is a principle of utmost good faith which you can apply to your case.There was no wilful concealment of facts on your part. After ten years the principle of "incontestability" should also apply.
Whatever, you have the right of claim.

Anonymous said...

You should make this case public. Then we know which company is it.

Anonymous said...

Mr. Tan, you should know that congenital condition is specifically excluded. The fact that discovery is after 10 years or 20 years does not change the situation that it was not covered in the first place.

You can suggest that the ph appeal on compassionate grounds but not suggest to him that it is his right.

Tan Kin Lian said...

If the anonymous person who posted the comment at 9:36 am wish to bring up a point to challenge me, I suggest that he should state his true identity.

I know that insurance is to provide certainty, and that any exclusion should be applied fairly. I know that some claim officers are quite quick to declare a condition as congenital.

I think that this should be certified by a doctor acting independently.

I do not know what is the specific medical condition that has been declared congenital that was discovered after more than 10 years. Even if it was told to me, I am not medically capable of determining if it is congenital.

Anonymous said...

Mr. 9.36am, agree that congenital
condition is excluded but at the point when the policy was taken it was not known to the applicant. That was no wilful non disclosure or even an oversight. Ten years after it should be accepted in good faith and as incontestable. It would be unfair if the claim is not admissible.

Khiat Han Hwee Adrian said...

If the insurance company has its stand that a certain condition is congenital, it will be the onus of the Policyholder to determine otherwise. The cost is being transferred to the Policyholder and it is unfair.

The policyholder should report to FIDReC for a third party view.

Congenital Anomalies is one problem. Some companies also exclude Hereditary conditions. It can even be harder to determine if a condition is hereditary at time.

Anonymous said...

Congenital or not depend on doctor's report and finding.

I have a client that submitted a claim and claims officer stated that it is a congenital condition.

I asked the insured to get the doctor to certified that such condition is not necessary congenital and claim was paid off.

Whether congenital or not depend on the doctor and not totally decided by claims officer.

- Thomas Phua

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