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Understanding why your Integrated Shield claims get queried or rejected

You have purchased an integrated shield plan (IP) hospitalisation insurance policy many years ago. You have never fallen sick so you have no experience in making a claim.

Understanding why your Integrated Shield claims get queried or rejected

As a private specialist, the author has helped many patients appeal against their integrated shield plan providers when their hospitalisation claims are queried or rejected.

You purchased an Integrated Shield Plan (IP) to cover hospitalisation charges many years ago. You have never fallen sick so you have no experience in making a claim on the insurance policy.

Then you recently got admitted for an illness. After discharge, the hospital submitted the claims for you electronically to your insurer.

You expected the claims to go through smoothly and you would just pay 5 per cent of the charges in co-payment, which should be fully covered by your MediShield funds.

But your insurer queried and rejected some of the items in your hospital bill.

How could it be? What can you do?

Most people encounter the above problem only when making a claim after an illness.

Just because they have bought an IP, or have even been issued pre-approval and a letter of guarantee (LOG) prior to the admission, it does not necessarily mean their claim will be reimbursed smoothly and fully after they are discharged.

As a private specialist, I have seen many such cases and helped some patients appeal when their hospitalisation claims are queried or rejected.

Here is a list of common situations that patients should be aware of when making a claim.

1. PRE-EXISTING SYMPTOMS 

Ms A consulted me for abdominal pain that had lasted for three months. I did a gastroscopy on her as a day surgical case. But her claim was rejected after discharge.

On further questioning, I realised that she had purchased her IP only a month before seeing me. This implies she had already had abdominal pain for two months when she bought the policy.

Pre-existing symptoms must be declared when purchasing an IP. Otherwise, hospitalisation resulting from the symptoms would not be covered.

Worse still, her abdominal pain has now become a potential pre-existing illness as it occurred before the purchase of her IP.

Her insurer may not cover any future conditions in her upper digestive tract.

2. PRE-EXISITING MEDICAL AND SURGICAL CONDITIONS

Mr B consulted me for rectal bleeding.

After performing a colonoscopy on him, I found a colon polyp, a precancerous condition, and removed it.

Yet his claim was rejected.

It turned out he had undergone a surgery for haemorrhoids six years ago. But when he bought his IP three years ago, he did not declare it.

Somehow, his insurer got to know the history of his old surgery from his family doctor.

At the time of purchase of an IP, patients must declare all their past medical or surgical history. Even seemingly unimportant history, like tonsillectomy or appendectomy, must be declared.

Not declaring any past medical or surgical history may nullify an IP contract.

3. INAPPROPRIATE INPATIENT REFERRALS

Mr C was admitted for abdominal pain. During his hospitalisation, he asked to see a urologist as he has some lower urinary tract symptoms.

A urologist who saw him diagnosed him as having a prostate problem.

But when Mr C made a claim, his urological consultation was not reimbursed.

The insurer’s rationale?

While abdominal pain and digestive endoscopy warranted hospitalisation, urological consultations could have been done as an outpatient.

Most IPs only reimbursed hospitalisation expenses. Outpatient consultations are generally not covered.

Most IPs would reimburse outpatient consultations and investigations only if that eventually led to an admission.

4. ADMISSION FOR AN OUTPATIENT CHECK

Many patients consult me for abnormal liver function test results or a liver nodule.

Often, further imaging studies like magnetic resonance imaging (MRI) or CT scan are needed. Some patients request to be admitted for such studies, as their insurers would only pay for inpatient investigations.

Many of my colleagues have found that such admissions would raise queries or even be rejected by their insurers.

Admission that are purely for imaging or laboratory tests will not be reimbursed.

5. TIMING OF POLICY

An IP policy does not start after signing the policy.

If a patient makes a claim within the first three to six months, his insurer would normally ask a long list of questions, mainly to ensure that his admission symptoms are not pre-existing ones prior to his purchase of the policy.

Most insurers are honest in this respect, and will honour the contract once they are sure the admission complaint had not happened before the signing of the policy.

6. SUPPLEMENTS AS MEDICATIONS

Supplements refer to over-the-counter medications that a person can purchase without a doctor’s prescription. Most insurers do not reimburse supplements, even if they are medically indicated.

For example, I often prescribe iron tablets for patients with anaemia, and S-adenosine methionine for patients with abnormal liver test results.

But often, their insurers would refuse to reimburse in these circumstances.

7. ACCESSORIES

While insurers would pay for the hospital bills, some items like a brace or a corset may not be reimbursed.

My orthopaedic colleagues often have to argue actively with their patients’ insurers that wearing a brace after a joint operation is essential to prompt recovery.

8. EXTENDED MEDICATIONS 

IP insurers typically provide post discharge medical care for three to 13 months, depending on the insurer and type of policies.

Patients have to be mindful that medications prescribed beyond the end of the period will not be reimbursed

For example, one insurer may provide post discharge outpatient care till 100 days after discharge.

If a patient is prescribed 60 days of medication on the 90th day post discharge, his insurer will reimburse only another 10 days’ supply of the medication.

9. NON-STANDARD TREATMENT

For many medical conditions, there are management guidelines from professional bodies.

For example, the American Association of the Study of Liver Diseases issues treatment guidelines for most liver conditions, such as viral hepatitis B and liver cancer. If I give inappropriate treatment for these conditions, I may be queried by the insurers.

Most insurers are reasonable and would agree to my management once I show them various management guidelines.

10. OTHER NON-MEDICAL EXPENSES

Some private hospitals offer non-medical perks, such as sparkling mineral water, and snacks in the patient’s room, similar to the minibar in hotels.

Many of these items are not free. Many insurers would refuse to reimburse these items, as they are not medically related.

Besides, some patients’ relatives or domestic helpers might want to stay with the patient during their stay in hospital. Their lodger beds and meals may not be covered by the insurers.

KNOWING YOUR POLICY

I  urge everyone to read the fine print of their IP policy before they fall sick.

They ought to know what items are claimable and what are not. And do declare all pre-existing symptoms, past medical and surgical history to the insurer while applying an IP.

One you fall sick, do inform your insurance agent who would advise you on the policies and post-discharge follow up.

Don’t be surprised if part of your claims are queried or rejected. Do discuss these matters with your doctor, who will usually help you write memos to argue for you.

My experience is that most insurers are reasonable and would be fair in assessing claims

But if there are further disputes, one can go to the Financial Industry Disputes Resolution Centre at for mediation.

 

ABOUT THE AUTHOR:

Dr Desmond Wai is a gastroenterologist and hepatologist in private practice. 

Related topics

Integrated Shield Plan health healthcare insurance

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