Friday, September 17, 2010

Case study - rejected claim under private Shield

It is best for a retiree to be insured under Medishield and be treated in a subsidised ward. This case study shows the risk and the stress of having an expensive hospital bill being rejected under a private Shield plan. Read:


rabbit7075 said...

Hi Mr Tan

i am interested to know is it possible for most singaporean to be warded in a subsidized ward class (B2/C)?

Do we need to go through means testing first? for example, before admission to hospital for operation, the hospital will ask which ward class we want....can we easily request for ward class B2?

medishield cannot help if we are not warded in a subsidized ward class....


simple said...

Generally it is said in the medical field that diabetes and high pressure increase the risk of getting other diseases affecting other organs such as heart and kidney. But not always are these other disease caused by diabetes or HP. Suggest the aggrieved concerned challenge the insurance co. to produce definitive evidence that his diabetes is a direct cause for the kidney stones. If they can't, then a non-declaration of his pre-diabetes illness is impertinent to the kidney illness he is suffering from and should not be enough justification to turn down the claim.


Tan Kin Lian said...

Reply to wanck75
Any citizen can ask to be treated in a subsidised ward. When you get your bill, the subsidy that you get will depend on means testing. If you are considered to be above the meant test level, the subsidy will be reduced according to your income level. The maximum difference is 15% of the hospital bill. For example, the subsidy is C class is between 80% to 65% of the hospital bill, depending on your income level. You can check the MOH website for details.

Spur said...

Hi Simple,

Unfortunately not so simple as telling the insurer "Eh, prove that my ailment is caused by diabetes/hypertension. Otherwise you better pay my claim!" The default stance is that such ailments are caused by pre-existing diabetes/hypertension. Not happy? Insure will tell you go Fidrec. And everybody knows how Fidrec operates.

Customer is expected to get expensive specialists to prove that his ailments are not caused by pre-existing condition. This is whether if go to Fidrec or sue in Court.

Imagine that a customer ia already stressed out over $20K hospital bill that cannot claim. Where got money, resources, energy and time to fight in Court? Besides having to hire expensive specialists, you need to also deal with expensive lawyers, expensive Court system, expensive courtroom fees, expensive judges etc.

If you got Private Shield plan, you can expect any claims to be carefully scrutinised, cross-checked across different hospitals, and investigated. Due to following reasons:-
1) Insurer is profit-making business, it's not running a charity, despite whatever nice-sounding slogans.
2) Customer will stay in higher class wards and use more senior specialists as supposedly covered by his Shield plan, so the bills are much more expensive.
3) Doctors will suggest using the newest drugs and procedures which are of course much more costly.
4) Customer may also have Riders that supposedly cover the deductible and co-insurance. Hence a big expense to insurer if claims is successful.

Insurers will pay if they cannot find anything to pick on. But if they find even a small fault, they can make things difficult for customer. Imagine if your year-end bonus depends on not exceeding certain amount of claims -- you will be damn "niow" (hokkien for stingy) afterall the customers are complete strangers and it will look good on your performance appraisal.

Parka said...

Some one should set up an insurance company that insures against the risk of claim rejection.

simple said...

To Spur,

I think you wrote from theory and with "ifs" and "buts". I wrote from real experience. Btw, contrary to common belief by many, FIDREC is quite pro-consumer and helpful, provided claimants do their homework and present their cases adequately. I have seen them in play more than once in insurance and non-insurance cases, all with positive outcome for the consumers.

Coming back to the case in hand, the onus of prove that the insured's diabetes directly caused his kidney stones condition is on the insurance company. Usually the insurance co. will rely on their in-house medical advisor to make a case to turn down a claim which is made on a desktop basis without physical examination of the insured. Actually, it may be difficult for them to prove that conclusively even if they seek medical report from the hospital that treated the claimant. This is because while diabetes may cause many diseases such as kidney stones, it may not be the cause for the specific situation of kidney stones. There are also other possible causes. To draw an analogy, drinking alcohol can cause liver cancer but not all liver cancers are caused by drinking. Any linkage between them has to be diagnosed and proven beyond a reasonable doubt.

The moral of the story is don't assume the worst, take a defeatist stance and let a big institution intimidate you. If you want yr money, fight for it (seek help if necessary) and don't just throw in the towel and blame everybody and everything.

hyom said...

From the comments, it seems that it is much harder to make claims with Private Shield than Medishield. Is this true?

I am asking because I bought Private Shield plans. I bought my plans in my late 20s.

Vincent Sear said...

As of now, means testing isn't fully implemented yet. Any citizen can opt for Class C or B2. However once you've opted for Class B2 or above, you can't downgrade upon your next warding or even outpatient treatment fees, without going through appeals with changes in circumstances, loss of jobs, business failures etc.

If and when means testing is fully implemented, it'll be at the first admission. No choice of class as it's determined by your means.

Blog Archive