Discussion board: Docs can’t be sure a process is claimable underneath medical insurance

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As a non-public specialist, most of my sufferers share the identical concern as Mr Tan Hong Choon about whether or not medical procedures are claimable underneath their Built-in Defend plans (IPs) (Let sufferers know whether or not procedures are claimable underneath insurance coverage, Could 12). Sufferers are anxious that their IPs is not going to cowl their medical bills after they fall sick.

However whether or not sufferers’ medical bills will be reimbursed relies upon solely on the contract between the affected person and the insurer. Docs have no idea with 100 per cent certainty if the claims can be profitable.

Completely different IP suppliers have completely different insurance policies. For example, it was just lately reported that some insurers don’t reimburse sufferers for most cancers medicine that aren’t permitted by the Well being Sciences Authority to be used in that setting, whereas others choose on a case-by-case foundation (MediShield Life, some IPs cowl off-label use of medicine for most cancers, April 21).

In 2020, one IP supplier abruptly stopped permitting claims for diagnostic endoscopies. That supplier made a U-turn solely after a public outcry.

Even insurance coverage brokers, who promote the coverage to the consumer, can’t be 100 per cent sure as it’s the IP suppliers’ claims division which decides on the deserves of every declare.

I deal with greater than a thousand circumstances of day surgical procedure and admission yearly. Greater than 99 per cent of my sufferers haven’t any drawback making profitable claims.

Nonetheless, insurers are likely to query the claims if the admission includes a pre-existing or excluded situation, if a declare is made shortly after a coverage is bought, if the process or investigation doesn’t require admission, if the admission is said to self- hurt or substance abuse, or if the admission is for a screening process.

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A number of IP suppliers require pre-authorization approval, whereby medical doctors must submit their medical plan and estimated fees for the insurer to approve. As soon as permitted, the insurer would subject letters to the hospitals to ensure reimbursement. It’s further work for medical doctors, however provides reassurance to sufferers.

I all the time inform my sufferers that I’ll give remedy that’s acceptable to their diseases. However whether or not they could make a profitable declare is between the sufferers and their insurers.

Desmond Wai (Dr)

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