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Hospital claim rejected due to exclusion
10 Nov 2017 (82 views)

I have often advised elderly people to stay with Medishield Life and avoid upgrading to a private shield plan. Recently, I was approached to assist the family on this case. 

Mdm X was an elderly lady. She was not literate in English. A few years ago, she received a letter from an insurance company to upgrade her shield plan to a higher plan covering private hospital.

She was asked to go for a medical examination for the upgrading. She did. The insurance company found some medical problems and offered her an upgraded plan with many exclusions. She was not aware about the significance of the exclusions. She signed her acceptance.

Some time later, she was admitted into a private hospital for a heart procedure. The insurance company issued a letter of guarantee to the hospital to pay the "covered expenses".

The treatment turned out to be more complicated than indicated earlier by the doctor. She stayed in ICU for several weeks or months. The hospital bill turned out to be $700,000. 

The insurance company rejected the claim as the treatment of her heart condition came under the exclusions. It was at this time that the children learned about the exclusions in the upgraded plan. They considered the terms to be quite unfair.

She brought her case for arbitration and lost the case. The insurance company refused to pay the bill. The family could only managed to pay $300,000. They have a balance of $400,000 outstanding.

The hospital took up a bankruptcy order against Mdm X for the balance.

The family suffered stress over this issue for many months.

If Mdm X had not upgraded to the private shield plan, she would have been treated in a public hospital. The bill would have been much lower. 

Many people may not realize the risk of going to a private hospital and incurring a very large bill, only to have the claim rejected by the insurance company.

Some of the reasons for rejecting the claim include alleged non disclosure of past medical history, or application of exclusions.

In this case, the insurance company should not provide a letter of guarantee for a treatment that is not covered under the policy. They owe a duty to Mdm X to advise her that the treatment would not be covered, due to the exclusions. If Mdm X knew about the exclusion, her family might have decided to get her treated in a public hospital.

As the insurance company failed to inform Mdm X, it has caused the family to proceed with the treatment in a private hospital and incurred a large bill that they cannot afford to pay.

Tan Kin Lian

 


Hospital claim rejected due to exclusion
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I have often advised elderly people to stay with Medishield Life and avoid upgrading to a private shield plan. Recently, I was approached to assist the family on this case. 

Mdm X was an elderly lady. She was not literate in English. A few years ago, she received a letter from an insurance company to upgrade her shield plan to a higher plan covering private hospital.

She was asked to go for a medical examination for the upgrading. She did. The insurance company found some medical problems and offered her an upgraded plan with many exclusions. She was not aware about the significance of the exclusions. She signed her acceptance.

Some time later, she was admitted into a private hospital for a heart procedure. The insurance company issued a letter of guarantee to the hospital to pay the "covered expenses".

The treatment turned out to be more complicated than indicated earlier by the doctor. She stayed in ICU for several weeks or months. The hospital bill turned out to be $700,000. 

The insurance company rejected the claim as the treatment of her heart condition came under the exclusions. It was at this time that the children learned about the exclusions in the upgraded plan. They considered the terms to be quite unfair.

She brought her case for arbitration and lost the case. The insurance company refused to pay the bill. The family could only managed to pay $300,000. They have a balance of $400,000 outstanding.

The hospital took up a bankruptcy order against Mdm X for the balance.

The family suffered stress over this issue for many months.

If Mdm X had not upgraded to the private shield plan, she would have been treated in a public hospital. The bill would have been much lower. 

Many people may not realize the risk of going to a private hospital and incurring a very large bill, only to have the claim rejected by the insurance company.

Some of the reasons for rejecting the claim include alleged non disclosure of past medical history, or application of exclusions.

In this case, the insurance company should not provide a letter of guarantee for a treatment that is not covered under the policy. They owe a duty to Mdm X to advise her that the treatment would not be covered, due to the exclusions. If Mdm X knew about the exclusion, her family might have decided to get her treated in a public hospital.

As the insurance company failed to inform Mdm X, it has caused the family to proceed with the treatment in a private hospital and incurred a large bill that they cannot afford to pay.

Tan Kin Lian