Complaints about Unsuccessful Medical Insurance Claims
Prime Minister's OfficeSpeakers
Summary
This question concerns the monitoring of unsuccessful medical insurance claims and the frequency of rejections for non-disclosure of health information, as raised by Ms Carrie Tan. Senior Minister Tharman Shanmugaratnam noted that while MAS monitors complaint trends, less than 5% of health-insurance complaints involve non-disclosure issues. He stated that insurers must prove non-disclosure is material and reasonably expected to be declared before rejecting a claim on those grounds. Most claim disputes involve coverage exclusions, claim limits, or lapsed policies rather than non-declaration. Senior Minister Tharman Shanmugaratnam also highlighted that policyholders can seek resolution through the Financial Industry Disputes Resolution Centre or the Clinical Claims Resolution Process.
Transcript
47 Ms Carrie Tan asked the Prime Minister (a) whether MAS monitors the annual number of complaints brought by citizens through the relevant channels regarding unsuccessful claims for medical insurance; (b) if so, what percentage of these complaints arise from claims rejected by insurers citing non-declaration of relevant health information; and (c) whether there are data or studies that show the typical number of such incidents reported and what is the probable number of unreported cases.
Mr Tharman Shanmugaratnam (for the Prime Minister): MAS expects insurers to be fair and reasonable to all policyholders, including not rejecting health insurance claims on the basis of undeclared minor and unrelated conditions. MAS closely monitors the trends for complaints lodged with MAS.
In the past three years, about 20% of health-insurance related complaints made to MAS were due to unsuccessful insurance claims. Of these complaints relating to unsuccessful claims, the majority was concerned with treatments not being covered under the insurance contract, claims that exceeded claim limits or were made after the policy had lapsed, or failure to submit supporting documents required by insurers to assess the claim application. Less than 5% of health-insurance related complaints received by MAS over the period pertained to unsuccessful claims due to non-disclosure of health conditions.
To reject a claim on grounds of non-disclosure of health conditions, insurers must demonstrate that the non-disclosure is material to the underwriting outcome and that the applicant could be reasonably expected to have disclosed the information during the application for the policy.
Policyholders who feel their claims have been unfairly rejected and are unable to reach a satisfactory resolution with the insurer may file a claim for mediation or adjudication at the Financial Industry Disputes Resolution Centre (FIDReC). MOH has also established a Clinical Claims Resolution Process (CCRP) for Integrated Shield Plan claim disputes of a clinical nature, such as whether claims were unfairly rejected for medically appropriate treatment or procedures, or whether there was over-charging or over-servicing by medical practitioners.