Insurance Claims Declined due to Difference in Definition of Medical Terms

7 Dr Tan Wu Meng asked the Minister for Health (a) since 2020, how many appeals have been received from Integrated Shield Plan insurance policyholders regarding their difficulties in making a claim that arises from the insurers’ definition of medical terminologies which diverge from how members of the public, laypersons and medical professionals may interpret the same terms; and (b) what recourse do affected policyholders have.

The Senior Parliamentary Secretary to the Minister for Health (Ms Rahayu Mahzam) (for the Minister for Health): Deputy Speaker, MOH does not track the number of appeals made by Integrated Shield Plan (IP) policyholders against an insurer’s interpretation of definition of medical terminologies.

Policyholders who feel that their claims have been unfairly rejected and are unable to reach a satisfactory resolution with their insurer may seek recourse from the Clinical Claims Resolution Process (CCRP) if the IP claim disputes are clinical in nature. Policyholders may also approach the Financial Industry Disputes Resolution Centre (FIDReC) for assistance with other types of disputes.

Mr Deputy Speaker: Dr Tan Wu Meng.

Dr Tan Wu Meng (Jurong): I thank the Senior Parliamentary Secretary for her answer. I declare that I am a medical doctor at a public hospital.

Sir, in The Straits Times Forum on 7 October 2022, an insurer was reported to have rejected a genuine claim on a technicality because the wording did not match a keyword, even though laypersons, healthcare professionals and the customer's own legal advisor felt the claim was correct. The company eventually admitted the claim. I have met Clementi residents and fellow Singaporeans facing similar difficulties.

Can I ask the Senior Parliamentary Secretary, first, when such wrong decisions are overturned on appeal, is there any requirement for the insurer to look back at earlier cases to see if there were other legitimate, valid claims that were incorrectly denied?

Second, I have met fellow Singaporeans whose IP insurers said the hospital bill needed particular words or phrases in order for a genuine claim to be allowed. This became a problem for some patients using their private insurance at a public hospital, because the public hospital billing format is standardised and may not match the insurer's technicalities and technical requirements. What recourse do these patients have and would MOH be willing to look at this further to see if these are isolated cases or reflect a more systemic concern?

Because, Mr Deputy Speaker, we must not have a situation where a genuine claim cannot go through just because the customer is less literate, less eloquent and does not have access to their own legal team.

Ms Rahayu Mahzam: I thank the Member for the question. I think these are legitimate concerns, especially if it involves laypersons who may not have access to legal advice on the matter.

MOH and the Monetary Authority of Singapore (MAS) work very closely in exercising regulatory oversight over the IP insurers. And MOH and MAS expect IP insurers to treat the policyholders fairly. So, when MAS is alerted of any unfair claims or mishandling of practices through its own ongoing supervision of insurers or through complaints received, it will investigate and take the necessary action to pursue this matter with the insurers. And part of it is to also ask the insurers to review past cases and compensate the policyholder when necessary.

Dr Tan also asked about the recourse that is available to the policyholders in such situations when there is difficulty in processing their claims. I have explained earlier the two platforms for the recourse that the policyholders have. One, it is the Clinical Claims Resolution Process (CCRP) if the IP claim disputes are clinical in nature. The other one is through FIDReC, where it includes other types of disputes. FIDReC is an independent institution and it is set up specifically to handle disputes involving all types of retail, financial products and services. So, they are best-placed to deal with these situations. They also provide mediation and adjudication services. This is something very helpful to the policyholders.

There is also CCRP, as I mentioned earlier, which is administered by the Academy of Medicine Singapore. It helps to deal specifically when there are issues relating to clinical matters pursuant to the IP plans.

At the end of the day, I think the first step is to go back to the insurers and see how it can be resolved. Because each IP provider would have their own dispute resolution process. If there is, indeed, some difficulty and unfairness, they can go through these two dispute resolution processes. Alternatively, if Dr Tan is aware of any specific cases, please refer them to us.

On his point about whether we will be looking into this, if there are specific cases that can be referred to MOH, we will definitely take a look and see how we can improve the processes to facilitate the claims made by policyholders.