Difficulty with Shield claim

Hi Kin Lian,
Trust & integrity from insurance companies are indeed important especially when it comes to claims. I wish to share my experience.

When I had an operation, I made a claim under my private shield insurance cover which came with enhancement including a rider for 100% coverage. These enhancements were purchased at a later stage and came with certain medical condition exclusions but it was stated specifically in the insurance cert that my original shield cover remains in tact and not subject to the exclusions. So whatever the issues arising on the exclusions, the minimum valid claim at least under my original cover would have been $X which was a substantial amount of the total medical bill. 

The key point I want to share with you and thru you to others is that initially my claim under my insurance policy for 100% cost was Totally DECLINED on the basis of dispute on the exclusions despite the above said minimum claim entitlement. It was errorneous and yet it took me a few months and a string of correspondences on deaf ears and only after finally a visit to their office to physically point out to them the relevant clauses in the insurance before they humbly and embarrassingly acknowledged to pay the $X claim amount unconditionally and immediately. Because of my perseverance and knowledge of the insurance terms, I prevailed. 

But if this is the way insurance companies administer claims and have an apparent built-in resistance to claims (possibly for profit-enhancement reasons), it is very wrong and unethical because there are many insureds out there who are less educated, informed or able to raise these issues and fight for their rights. Why should insureds even have to fight at all for their rightful dues? Shouldn't the company have qualified professionals to process claims independently and objectively according to the T&C of each cover? What form and standard of corporate governance does it have?

As an aside: the good news was that I won on my full claim in due course after almost a year of aggravation because the insurance co. ultimately backed out from the adjudication process. I cannot go into the details of the winning arguments except that one more positive that resulted was that the company was found to be unfair to both charge higher premiums for medical conditions and at the same time impose exclusions on the same medical conditions which amounted to a double whammy, and I got my premium reduced. Something is therefore also unfair with its underwriting process. 

I hope you can share your comments in a general manner on the latter as well as the claim process to alert the public and others who are similarly aggrieved. 


REPLY
It is wrong for an insurance company to reject a legitimate claim in a careless manner. In some states in America, it is illegal for an insurance company to deny a claim without a valid reason. If they make a mistake or are are malicious, they have be fined by the authority or have to pay damages to the policyholders. This is stated in the text book that I used to teach risk management.

An insurance company has a duty to treat its customers fairly. Rejecting a valid claim is a serious breach of duty and breach of trust. The policyholder should not be put to so much trouble or distress in making a legitimate claim.