Is balloon angioplasty (the technique of widening obstructed arteries typically in the heart) a surgical operation?
And, does being hospitalized for 2 days mean being confined in the hospital for 2 days?
The answer, in both instances, is in the negative under the terms of certain insurance policies, thus depriving the insured of indemnity by their respective insurers.
Such problematic issues were brought out in complaints to the Council over the scope of insurance coverage, and the terms and conditions of the policy that are less than clear and transparent to the insured.
In the former case, the complainant bought an insurance policy for critical illness protection through an intermediary in 2006. Coverage, as expressed in the insurance proposal, clearly included coronary artery disease and other heart-related illnesses.
In 2013, the complainant was diagnosed with severe obstruction of the coronary arteries, requiring balloon angioplasty operation. Afterwards when he sought indemnity under his insurance policy, he was rejected by the insurer on grounds that such operation was excluded in the scope of coverage.
As it transpired, the Supplement Provision of the policy provided a detailed definition on coronary artery disease which is within the scope of coverage, that is, coronary artery disease requiring surgery, but balloon angioplasty is regarded as non-surgical technique and is therefore excluded under the policy.
However, as alleged by the complainant, the insurance intermediary has never explicitly mentioned this point to him before the policy was purchased.
In the latter case, in 1991 the complainant bought a medical benefit insurance policy which provided for a daily cash allowance for hospital confinement. According to the complainant, the agent orally explained that the number of days of hospital confinement will be based on the hospital's actual charges.
In 2013, he was admitted to hospital for an operation, and was released the following evening. The hospital charged him for 2 days of ward boarding. But when he lodged an insurance claim he was indemnified daily cash allowance for one day only.
It transpired that the policy stipulated that the day of hospital confinement means each continuous 24 hour period of confinement in hospital. Since he was hospitalized for only more than 24 hours but not continuously for 48 hours, his claim for 2-day allowance did not satisfy the definition for 2 days.
Upon the conciliation of the Council, the dispute was settled to the satisfaction of the complainant.
In advice to consumers contemplating insurance service, the Council has stressed the importance of carefully reading the terms and conditions of the insurance policy and making good use of the cooling-off period (if applied) made available to consumers purchasing long term insurance products.
Consumers are also reminded to fulfill their obligation of full and accurate disclosure of their personal information which is relevant to the insurers' decision on whether to accept the insurance application and on what terms and premium.
The complaints have highlighted that some insurers, when promoting their products, may not have fully observed the legal obligation of utmost good faith, that is, to give full and accurate disclosure of information relevant to the policy, such as the scope of coverage and exclusions. Often consumers cannot be reasonably expected to fully understand the content of lengthy and complicated insurance policy on their own.
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- 2014.07.15