Friday, December 04, 2009

Low payout for medical claim

Hi Mr Tan,
I saw this article on the forum last week but till now I have not seen any reply from Income on it (Normally companies will be quick to respond to letters in the ST forum).


Can you comment on why an expected payout of $3,600 can end up to be only $240?
Maybe you can even share this in your blog.

Puzzled by insurer's payout for medical claim

RECENTLY, my wife was hospitalised at Mount Alvernia Hospital for four days. Her medical bill came up to $7,995.15.

She is insured under Income's IncomeShield Plan MA, but the total payout by Income was a shocking $240.
I called Income to find out how it arrived at that sum and was told that technically the $7,995.15 was classified as "room and board", hence limiting the claim.

The $7,995.15 included a renal screen, bed charges, clinical consumables and supply, diagnostic imaging services, equipment use, laboratory services, outside hospital services, pharmacy cost, resident medical officer fees, treatment fee and doctor attendance fee.

Given a deductible of $4,000 per policy year and 10 per cent co-insurance, any man in the street would expect an insurance payout of $3,595.63. But this is not the case.

My wife has faithfully paid her premium for the past 15 years without a single claim and this is what she gets in return. I am writing this so the public is made aware of such pitfalls in their medical insurance.

For big insurance companies to cite a technicality as an excuse not to make a decent payout is in no way fair. I urge the Consumers Association of Singapore and leaders in the insurance industry to look into this loose definition of "room and board".
In my opinion, given my wife's good record, Income should honour the $3,595.63 payout as a goodwill gesture.

Lastly, I would like to ask the Central Provident Fund Board why only $450 a day can be used from Medisave for hospitalisation.

Ong Kok Lam

28 comments:

Tan Kin Lian said...

I will write a separate article about this type of medical expense claim in a few days time, when I am back in Singapore.

A medical expense claim is subject to sub-limits (for each type of charge), pro-rated bills (if you visit a private hospital), co-insurance, deduction, and exclusions.

This is confusing to the insured, and usually result in lower payout than expected.

This type of problem occurs frequently in America, leading to the need for Reform of the Health Care system.

My Foot said...

I have always known this.

" One should have Hospitalisation & Surgery Insurance!"
Many in this blog seem to support this type of insurance. I disagree.

This type of policy is just as poorly designed as other insurance products. You will only find out when you file a claim.

My wife tried to claim once and was able to get a small sum. There are so many vague terms that the insurance company will list as not part of the cover. If that is so, then the product should list down very clearly what is claimable and what is not.

The list of claimable diagnostic costs is already a minefield! Only certain types of diagnostics and from selected hospitals or treatment centres.

The questions that ordinary people should ask of an agent is this: What can I claim? How do I claim,What are the documents that I need to submit, Show me a claim form and explain it.

If they are unsure or keep avoiding the issues such as " aiyah! why think about this thing now? Think about happy endings!"

Walk away and do not turn back!!

You can conclude that the agent is incompetent.

Belinda said...

Hi Mr. Tan,

Appreciate your input as i am interested to purchase NTUC Ehanced Medishield for my parents in their mid 50.

Pls advise. Thanks

Anonymous said...

The bottomline is the reason why insurance companies are here in the first place. During TKL time the mission is clear, to alleviate human suffering and to help when people are down. Now it is profits, profits, profits, as seen on the advertisement screen in every NTUC Income branches. It is not only health insurance. Hundreds of thousands of policyholders will not know what is entailed until they claim. Many are not even around to see the frustrations of their loved ones when their grieving are compounded by the frustrations of going through a minefield of administration and technical difficulties in the claiming process. Take travel insurance, when you lose something and found out only when you return to Singapore, insurers will want you to furnish a police report. The problem is when you leave the place of embarkation you are not aware of the loss until you arrive in Singapore. Would the Singapore police accept your report for things that are not lost in Singapore? So that is a technicality.
Or when you claim for personal accident. They will not tell you which clinics are acceptable till they process your claim, which usually takes more than two weeks. By that time, either your injury became more serious if you wait for their confirmation or you would have spent quite alot visiting a TCM clinic that they later tell you they do not recognise.
And the list goes on, as long as the management is thinking of their own KPIs and profits and bonuses, you can be sure that everything is done legally right and you have no recourse except frustrations and redtape until you give up. For every Mr Ong Kok Lam who complain there are a thousand others who just kept quiet and think it is their own bad luck. That is how it is today. Peace of Mind, fair treatment? They are referring to their ownselves. If the choice is between pay and get frustrated, then it makes sense to self insure from now onwards.

Anonymous said...

Hmm, if Income said that the $7995 is Room & Board, then the payout shld be $690 X 4 days = $2760?

$690/day is the R&B limit for MA Plan, including "medical related services". Unless Income says all those tests, screenings, medicine, CTScan, doctors fees etc not part of the "related services"?!

Even then, I don't think Mt Alvernia merely charges $240/4 = $60 per day for ward, right?

Anyway the unfortunate customer was also using wrong cover for wrong hospital. MA Plan is "theoretically" meant for Govt A-class ward, not for private hospital. Unfortunately, many of the sub-limits in the MA plan are outdated, applicable more for the early 2000-2003. If open surgery is involved, this plan can safely cover only B1-class charges.

Ex-Con

Anonymous said...

Just refuse to buy. Simple.

Vincent Sear said...

I think that healthcare insurance has to be properly matched with expectation and intention:

MediShield : Government Class C
CPF-Approved Shield B : Government Class B2/B1
CPF-Approved Shield A : Government Class A
Private Cash Plan : Private Hospital

Anonymous said...

Don't think the medishield is the best. My mum has medishield and seeks treatment in KKH. The amt deducted from her CPF medisave a/c was in a mess; imagine cost incurred in Dec 2008, being deducted only recently. There is no way to counter-check despite writing to KKH and CPF many times.

Time for a reform!

starlight

Anonymous said...

Dear all,
I feel sad for Mr Ong for receiving such a low payout ($240) from Income.

I like to highlight that it seems that Mr Ong does not know / understand the following:

1. There is limit to Room and Board for his wife policy (in this case:$690/day). It is not the " As charged" in some policy like the enhanced Incomeshield.

2. Most treatments (especially not surgical) must be charged under Room and Board. This is done so that all tests/ treatments/ consultation fees can be covered. If it is not so, then the entire policy will be very complicated...

3. The policy works well with government hospital not private ones. The question is if Mr Ong's wife was admitted to KKH instead of MAH, the total cost incurred will not be that high.

Lastly, my entire family is insured under NTUC Enhanced Incomeshield (with old rider). My daughter was hospitalised (KKH) and everything was promptly paid up. No question asked. My father went for cataract operation (TKSH) and the paid up was prompt and hassle free. I think the important thing is to know what you are insured? What coverage? If not sure, ask. The NTUC helpline is wonderful.

Anonymous said...

It was not the first case. 1 year ago, she got cents.

Thank you Mr TKL to tell us more.

Anonymous said...

That is why I only buy limited insurance. When I was younger and employed, the company(MNC) covers all my needs and I have good luck in health for me and my family too. Now that I am semi retired, I bought only medishield and a fire and public liability insurance for my rented condo. Anything else, I self insured as I dont really trust the insurance companies. You pay your premium and when you make a claim, all sorts of excuses.

I remember my sister who has mnedishield and she was warded in private hospital. The hospital charges were 6k. I think she got back 250 only.

Anonymous said...

classification of room and board is done by the hospital, not the insurance company.

Anonymous said...

I had the same runoff with NTUC in late 2008 when I filed for a claim. There was no response to emails, they dont return my phone calls..in the end I got so angry that I said "forget my claim"...And since then there was no follow thru from them. And this after many many years of zero claims with NTUC. NTUC is horrible in my opinion. Take heed.

Anonymous said...

i have an unrelated question.
what happens if i die and also lose all my policies cert (because house burnt down)

how does the survivors know what policies do i have so that they can claim insurance ?

Anonymous said...

Why did he choose a private hospital when he has a chance to go to a government hospital?

For a 4 day stay with no surgery and the bill came up to almost $8000, that's very expensive!

It's like $2,000 a day! Why did she choose not to stay in a C-class or B2-ward?

Is it the common sense thing to do to check with the hospital first what is the estimated bill size and later check with the insurer to see how much is claimable before admitting into the particular hospital? Also, shouldn't he check with the other hospitals and find out the rates first before choosing one that cost so much?

I always do that when I visit the hospital and get the best rates before admitting into the hospital.

Just like buying insurance, it's better to do your own homework first before buying a service right? Furthermore, all the hospitals rates are readily available.

Now slapped with big bill and found out cannot claim so much then push all the blame to insurer. I think the consumer also need to do some homework before choosing a service that is beyond his means to pay.

Anonymous said...

For the guy who's worried in case policies all burnt up ... you should list down all your policies and inform your family members beforehand. With your NRIC number, policy numbers, death cert and proof of relationship, your family can then settle with the insurers.

Now everything in computer records ... no reason for having to produce the bits & pieces of policy certs in order to claim.

Anonymous said...

Private hospitals simply overcharge, assuming that patient can claim from their insurance company.

Anonymous said...

I had the same runoff with NTUC in late 2008 when I filed for a claim. There was no response to emails, they dont return my phone calls..in the end I got so angry that I said "forget my claim"...And since then there was no follow thru from them. And this after many many years of zero claims with NTUC. NTUC is horrible in my opinion. Take heed.

December 04, 2009 10:21 PM

This is the way they make you give up your claim. Your experience is in 2008, that is when the new management took over and slowly all these cunning moves seep in. What to do, if you have a wolf in charge, all the chickens will slowly be eaten alive.

Anonymous said...

NTUC now is No Trouble Until Claim

and No Tan (TKL) U cry.

What they publish in their ads recently is what they do opposite in reality. It has become profit centric and not people centric anymore as in TKL time.

Anonymous said...

The devil never speaks the truth, right? The devil also says good things but does evil things, right?

Anonymous said...

CONFESSION OF A SO CALLED REGULATOR

Read what Ng Jia Jun, Assistant Director, Capital Market Intermediaries of MAS has to say.
He is trying to say that MAS is useless and powerless to deal with FIs.He might step on the somebody's toes.
The question is, is MAS a regulator? or some kind of protection outfit for the FIs.Compared to UK FSA, MAS is a mockery, castrated, toothless only good for history.

"MAS is unable to resolve commercial disputes between consumers and
their FIs, or order FIs to pay compensation to them. MAS expects all FIs to
handle consumer complaints and feedback independently, effectively and
promptly. We expect FIs to take responsibility to explain themselvesand
respond to their customers. As such, when MAS receives a query or complaint
from a consumer against an FI, our approach would be to forward thematter
to the FI concerned and instruct the FI to reply directly to the consumer,
with a copy of its reply to MAS. Consumers who are not satisfiedwith the
FI's reply can consider approaching the Financial Industry Dispute
Resolution Centre (FIDreC), an independent and impartial organisation that
specializes in the resolution of disputes between FIs and consumers,or
exploring other avenues for recourse.

As stated in the Fair Dealing Guidelines, where there are any
failings by the FI in relation to obligations stipulated under the FAA, MAS
will continue to take supervisory or enforcement actions against the FI. Our
supervisory dealings with financial institutions are generally confidential."

This statement is as good as telling the investors, who sufferred losses due to FI's ill practices and competency, your matter raised is already "closed" at FI and neither the investors will get to know whether MAS will enforce any action or not againsts wrong-doing FI because it is a close-door issue.

Anonymous said...

How can MAS offend FIs? The FIs run MAS indirectly, isn't it true?
MAS is only good to deal with Loan Sharks or Ah Long becuase they take the business away from FIs.
FIDREC? it is like throwing chickens into a pan full of wolves.The victims become the accused.

Anonymous said...

it is expected..Looking at how it behaved, half heartedly, it was a signal to us consumers that MAS should not be involved when we are in trouble with their protege. MAS is not a regulator.It is just another agency to facilitate the FIs to make more money.
Consumers are customers of the FIs and insurance companies. If you have not opened your eyes big big it is your business. It is caveat emptor.

Anonymous said...

Soon everyone will be educated financially with the setting up of the Financial Literacy Institute. Every consumer will become expert and savvy and can judge and evaluate products and make informed decision.
In other words consumers are on their own. This seems to be the views of MAS, although they differ from some financial experts who think no matter what consumers need protection from the rogue FIs, insurance companies with their equally rogueish agents and RMs..
Anyway, it is no surprise. MAS had this view since 2001 when it mapped its plan to be the financial hub and adopted Caveat Emptor as the basis of any financial transaction and MAS 'helps' to facilitate it by the requiring the vendors to disclose (what?)so that the consumers can make informed decision with exception of some old 'vulnerable' folks with primary education.
MAS is saying to us not to rely on them for enforcement and adjudication . Please deal with the rogues or the wolves who sold you the products when they go awry. We take our hands off. We believe in self regulation. They are big boys ,they should know what they are doing. Indeed, the 3 big boys and the 4 big girls know what they want and they are doing what make sense or rather cents to them.
Good bye , consumers, it is the era of chiki kuchiki.

Hard headed said...

Remain resolute.
Do not buy any product from any agent .
Remain resolute.
Come rain or shine... do not buy.
Save your money and go for a holiday.

Remain resolute.

Anonymous said...

Anonymous said...
I had the same runoff with NTUC in late 2008 when I filed for a claim. There was no response to emails, they dont return my phone calls..in the end I got so angry that I said "forget my claim"...And since then there was no follow thru from them. And this after many many years of zero claims with NTUC. NTUC is horrible in my opinion. Take heed.


To the guy who said he was not able to make a claim, do u have any representative servicing u from NTUC Income directly? If not, maybe u shld call the hotline. It's not possible for insurance company not to pay claims. It's also illegal to do so. If u want to claim, maybe my aunt can help you, she's one of the top consultant in NTUC Income.

Anonymous said...

You pay commission to the agents to make claim. This is what they would tell you. Without them you can't claim. Very lucrative, hor...ntuc is good for telling you this. If you think you won't make any claim why should you pay these agents commission, right? NTUC agents are good for this kind of talk. It is threatening talk.

Anonymous said...

Dear Mr Tan,

I am looking forward to your posting on this subject for I am considering to buy a medishield policy and a hospital cash policy. The latter, in my simple opinion, would hopefully cover the co-insurance & deductible and other medical expenses not claimable under the medishield one. I am in my late 40s now. Also, if you could share the definitions of pre-existing conditions and it's ramifications relating to claims and buying a H&S policy. Have talked with some insurance agents regarding definition of pre-existing. Their answers are quite standard, for example, if medical treatment has been sought for a condition prior, then it should be declared. I feel that is very vague and is does not help me decide to buy or not. Appreciate your views on this. Thank you.

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