Medical insurance policies are as varied as they are complex - little wonder many are unaware of the important provisions in them.
But it pays to read the small print carefully to avoid unnecessary hassle in later years.
Consumers are urged to pay attention to the provisions and exclusions in small print which are equally important, if not more, in addition to the premium and scope of cover in the choice of an insurance plan.
This followed a Consumer Council survey on 39 hospital and surgical medical insurance plans by 10 major insurance companies. Highlights of the survey include:
On premium, normally the younger the age, the lower the premium will be for policyholders. For example, the annual premium for the 39 plans surveyed ranged vastly from $943 to over $17,300 (aged 30), and $1,205 to over $22,200 (aged 40).
In general, the higher the premium the wider the scope of cover, the question is: do you really need that much protection and can you afford it.
On scope of cover, the survey covered comprehensively on a wide schedule of reimbursement for expenses, among them, daily room and board, intensive care, surgical expenses, anaesthetist's fee and operating theatre, outpatient treatment and care.
The survey found insurance policies generally define the term "medically necessary" as, for instance: "be consistent with the diagnosis", or "not for the convenience of the insured or the doctor".
A contentious clause such as the insurance company could make a final decision about whether a hospital visit was medically necessary was noticeably absent in the policies under survey.
However, some insurance companies have replied that they have the absolute discretion over whether a hospital visit is medically necessary.
Some policies stipulated clearly the limitation of the Surgical Expenses Benefit. For example, no benefit will be payable in respect of more than 1 procedure resulting directly or indirectly from the same disability; if more than 1 procedure is performed, only the largest benefit is payable.
Some policies offered the insured lifelong medical and hospitalization cover with guaranteed renewal but on conditions that, for example, renewal terms, conditions and premium rates are not guaranteed and may be adjusted by the company periodically.
The disclosure of medical history is of the utmost importance. This is the responsibility of an applicant when applying for medical insurance cover.
The rationale is: if an applicant provides inaccurate or incomplete information, the insurance company will not be able to assess and underwrite the risk accurately, as well as to apply appropriate terms and fix the premium based on the information provided.
Non-disclosure could result in policy repudiation and claim rejection.
Further, some policies contained a "waiting period" provision which means that no indemnity will be paid for medical expenses incurred due to all sicknesses within 15 to 30 days after the inception of the policies, or for medical expenses incurred due to specified illnesses, e.g. diseased tonsils requiring surgery, haemorrhoids, cataracts, etc. for up to one year.
Medical expenses incurred due to injury resulting from accident are not subject to this restriction.
Consumers should be wary of the illnesses, conditions or treatments which are not included in the covered items of policies.
These exclusions commonly included: routine medical check-ups and vaccinations; cosmetic surgery; pre-existing conditions (diseases or injuries); congenital and hereditary conditions; human immuno-deficiency virus (HIV); mental and psychiatric disorders; artificial limbs including prostheses, appliances and braces.
Remember also to adhere to the deadline for filing a claim under medical policies - generally within a specified period of 30 to 90 days - together with the medical receipt, doctor's report and relevant supporting documents.
Lastly, exercise your right on the cooling-off period (14 to 40 days). Should you decide not to confirm the policy, return the policy to the insurer.
In the first 11 months of this year, the Consumer Council has received a total of 82 cases involving mainly claim rejection, compensation and premium disputes, and service quality. There were 91 cases and 83 cases in 2008 and 2007 respectively.
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