PETALING JAYA: Disputes over health insurance claims are fairly common, judging by the number of cases handled by the Financial Mediation Bureau.
In 2010, the bureau heard 251 cases and ruled 142 in favour of policyholders and the rest for insurance companies. The following are a sampling of the cases:
A policyholder suffered an acute heart attack and an emergency coronary artery bypass surgery was performed. His medical report stated that he had been having mild diabetes for about two years.
The insurers rejected his claim on the grounds that the hospitalisation arose from diabetes and related complications. They based their decision on medical findings that diabetes is a risk factor for coronary artery disease. The attending doctor, however, said the heart attack was not due to his diabetes. The consultant cardiothoracic surgeon reported that the risk factors for the insured’s heart disease were smoking and high cholesterol.
The mediator held that the exclusion clause was not applicable and the insurers were liable to settle the claim.
An insurance company had rejected a hospitalisation claim that a policyholder made following a cataract surgery. It contended that the surgery had been done on an out-patient basis at the eye surgical centre. The insured argued that he was admitted to the Mount Elizabeth Medical Centre and was there for eight hours and that the eye clinic was based in the hospital.
The bureau found that the eye surgical centre was part of the registered hospital and the insurance company was liable to settle the claim.
An insurance company declined to settle the death claim of an insured mother who died.
The insurance company alleged that the mother was not covered under the policy. However, the insured argued that she had included both her parents at proposal stage and had been allowed to renew the same conditions yearly.
The company re-checked its re-cords and discovered that the insured had actually taken two separate policies: one for her and her spouse and the other for her parents.
The insurance company agreed to settle the claim.
A woman was hospitalised for breast hyperthrophy (extreme breast growth) and underwent breast-reducing surgery. The insurers rejected her claim on the grounds that the surgery was cosmetic.
The bureau drew their attention to the diagnosis of the doctor that the surgery was a form of treatment and not for cosmetic purposes.
The insurance company settled the claims.
Source: The Star, 27 Jan 2012.