Tan Kin Lian's Blog: Rejection of a critical illness claim

Thursday, April 24, 2008

Rejection of a critical illness claim

Dear Mr. Tan,

I bought a critical illness cover for my wife two years ago. Recently, she felt some pain on her breast and saw a doctor at the polyclinic. The doctor examined her and refererred her to Tan Tock Seng for further examination. She was diagnosed with breast cancer.

At the polyclinic, she told the doctor that she did a mammogram more than ten years ago. It showed a lumpy breast but The doctor at that time said that there was no need for repeat consultation. I called the clinic where she did her mammogram but was told that they could not find her previous record. My wife has all along been in good health until this unforseen illiness was detected last year.

The insurance company denied her claim becuase she did not disclosed the breast lump in her declaration form. There is no record on this matter except for her verbal conversation with the doctor at the polyclinic. Can the insurance company deny the claim? Please advise.

REPLY

I am sorry to learn about your wife's medical condition and the rejection of the claim by the insurance company.

I suggest that you write to the insurance company formally to request for the following facts to be put down in writing:
a) the coverage of the policy
b) the policy condition regarding non-disclose and incontestibility clause
c) the facts of the case, in particular the evidence of her previous medical condition
d) the reason for the rejection

If the insurance company wish to reject the claim, they have to duty to prove non-disclosure of a previous medical condition. It seems that the verbal conversation does not constitute sufficient evidence to support the rejection. You should keep a record of these correspendence. If you meet with the claim manager, you can also ask for their position to be put down in writing.

If you feel that the insurance company has been unfair in rejection of the claim, you can lodge a complaint with the FiDREC (Financial industry Dispute Resolution Center). http://www.fidrec.com.sg/website/faq.html

You can also refer this matter to a lawyer, but at a later stage.

7 comments:

Anonymous said...: Even an illness such as breast cancer is detected, I don't think the critical illness policy would immediately pay. The cancer has to be at some serious stages before this policy can kick in.

starlight.; April 24, 2008 7:52 AM
dsowerg said...: Mr Tan, I would like to seek your advice. I found some breast lumps and was referred to TTSH for followup. The lumps turned out to be cysts, which are very common in women and which have no correlation to the incidence of subsequent breast cancer (see link below).

When I bought a H&S policy from income, I declared this verbally to the agent, but the agent decided that it was trivial and thus did not write down on the declaration form.

Would you advise me to do a re-declaration? I did declare but the agent didn't write it down. Also, how reasonable are the actuaries in assessing the risk of cancer in case of a benign condition like cysts. Why is it that the actuaries cannot accept doctor's letters stating that the presence of a benign condition does not increase the risk of cancer? I had to keep fighting for coverage on another condition I had and even then, NTUC didn't give me full coverage.

Thanks for your advice.

http://www.cpmc.org/services/women/breast/breast_cyst.html#%3Cb%3EDo%20cysts%20lead%20to%20cancer?%3C/b%3E; April 24, 2008 9:48 AM
Anonymous said...: eve,
When you declare your cysts, the insurance company will then insure all other conditions except those that affect your breasts. So if you think that by declaring, you will get paid when subsequently breast cancer is detected then you are wrong. The insurance companies make you do a declaration to protect themselves.; April 24, 2008 1:50 PM
Anonymous said...: To poster of 1:50pm.

I think it is essential to declare your health truthfully.

The insurers are insuring you a big amount with that little premiums you are paying.

Insurance is about pooling of risk, healthy and unhealthy. If you don't declare your health, it is unfair to those who are in the same pool.

For whatever selfish reasons you have, I urge you to deal with things with fairness and honesty. You can always choose not to insure and opt for self insure.; April 24, 2008 4:44 PM
Anonymous said...: To anon 4.44,
Do not be judgemental. There are no selfish reasons except to share what I know to Eve, who may be thinking that by declaring then any future conditions of breast cancer will be covered. It is not so. I urge you not to be judgmental and to improve your reading comprehension and not jump to conclusions. I have always been fair and honest. In fact, honesty is a strong part of me. And talking about fairness, I think I live by it and will even die to fight for it. So be fair!!!; April 25, 2008 1:51 AM
Anonymous said...: To Anon 4.44,
There are no selfish reasons except to share what I know with Eve, who may be thinking that by declaring her cysts in breast she would be able to claim for breast cancer subsequently if she ever contracts it. I know that this is not true. I am not telling her not to declare but letting her know the truth which many insurance companies will not tell you until you try to claim. This is to ensure that she has her eyes wide open before she sign up for any insurance policies and not be treated unfairly later on.
Do not be judgemental and jump to conclusions. I have always been fair and honest. I urge you to improve your reading comprehension and be fair. In fact, fairness is always my top priority and I live by it and will even make big sacrifices to ensure it.; April 25, 2008 1:59 AM
Anonymous said...: To anon 1:51pm (1:51am, 1:59am),

You are right, my english not as good as you.

I read your post and it seemed to me that you implied that by declaring, the insurer is not going to cover her cyst anyway, so might as well don't declare - who knows she may get lucky and get paid!

If this is so, it is selfish, dishonest and unfair. We cannot have this kind of people around us.

Of course, if it is not, my apologies - if you actually meant that we must declare everything that we know to the insurer, I have no issues.; April 25, 2008 6:13 PM