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Health Insurance Claim

>> Saturday, October 10, 2009

I refer to the letter from Ms Cheam on 10 Oct 09 to the ST Forum regarding her claim from AIA HealthShield insurance plan.

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'Hospital bill totalled $5,969.13 but amount reimbursed was $128.61. Is mine an isolated case?'

MS CHEAM TEO SENG: 'I am insured under an AIA HealthShield insurance plan. I was warded for one day in Gleneagles Hospital for ankle surgery. The hospital bill totalled $5,969.13. Gleneagles submitted my claim for reimbursement to AIA, but the amount reimbursed was $128.61. AIA took three months to reply to my request for the discrepancy after I sent a complaint to its chief executive. The coverage provided by AIA has four categories, namely room and board, in-hospital expenses, surgery and implants and approved medical supplies, with limits on the reimbursed amounts in each category. Gleneagles prepared its bill under nine categories. Some items in the prescriptions category were injections used in the operating theatre. According to my family doctor, these items should be classified as approved medical supplies. When Gleneagles submitted its bill to AIA, it classified the prescriptions category as in-hospital expenses. These items were excluded from the claim reimbursement, as the amount exceeded the limit in this category. If they had been classified as approved medical supplies, they would have been reimbursable. Is mine an isolated case, or are many HealthShield policyholders paid less than what they are entitled to because of processing discrepancies?'
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There is insufficient information, but if she did not purchase the "As charged" plan and the rider, the claim amount is very possible. Based on the limits imposed, maybe she can only claim up to $3,142.90. Without the rider, she will have to pay the $3,000 deductible and 10% co-insurance. Therefore, claim reinbused is 90% of $142.90, which is $128.61.
 
She is probably covered under the older policies where the insurer has imposed limits to the reimbursed amounts as compared to the newer policies having the "As Charged" feature. My guess is that she had full confidence in what she has purchased and did not review her policies for a long time. Or her agent did not bother to update her of the changes and advise her properly about the policies coverage.
 
It is important to review your policies at least once a year to keep abreast with changes and updates lest you be left out of additional benefits.
 
She is probably not covered under the private hospital HealthShield plan and instead only the government "A" class ward. This may also be another reason why limits were imposed as she can only claim up the equivalent class ward amount.
 
She also probably also did not purchase the rider where the insurer will cover the deductables and co-insurance, so the first $3,000 and 10% of the remainder above will not be claimable. My guess is she wanted to save on premiums, but resulted in her not being able have the appropriate level of cover at a private hospital. Or her agent did not bother to do a needs analysis to advise a suitable plan for her.

It is important that you choose a plan that meets your needs and understand the level that you are covered.
 
Many times, people do not want to spend a lot on insurance or commit the time to review their protection as they deem it as unnecessary and a waste of time. It is only when a crisis happens that they start questioning their coverage and learn the importance of insurance. However, by then, nothing can be done already.
 
Do not have complete faith in your relative or friend agent that what they have planned for you is the best, there is no harm in seeking a second opinion just to be sure.

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