Forum: Doctors cannot be certain a procedure is claimable under health insurance

As a private specialist, most of my patients share the same concern as Mr Tan Hong Choon about whether medical procedures are claimable under their Integrated Shield plans (IPs) (Let patients know whether procedures are claimable under insurance, May 12). Patients are worried that their IPs will not cover their medical expenses when they fall sick.

But whether patients' medical expenses can be reimbursed depends solely on the contract between the patient and the insurer. Doctors do not know with 100 per cent certainty if the claims will be successful.

Different IP providers have different policies. For instance, it was recently reported that some insurers do not reimburse patients for cancer drugs that are not approved by the Health Sciences Authority for use in that setting, while others judge on a case-by-case basis (MediShield Life, some IPs cover off-label use of drugs for cancer, April 21).

In 2020, one IP provider abruptly stopped allowing claims for diagnostic endoscopies. That provider made a U-turn only after a public outcry.

Even insurance agents, who sell the policy to the client, cannot be 100 per cent certain as it is the IP providers' claims department which decides on the merits of each claim.

I handle more than a thousand cases of day surgery and admission annually. More than 99 per cent of my patients have no problem making successful claims.

However, insurers tend to question the claims if the admission involves a pre-existing or excluded condition, if a claim is made shortly after a policy is purchased, if the procedure or investigation does not require admission, if the admission is related to self-harm or substance abuse, or if the admission is for a screening procedure.

Several IP providers require pre-authorisation approval, whereby doctors have to submit their medical plan and estimated charges for the insurer to approve. Once approved, the insurer would issue letters to the hospitals to guarantee reimbursement. It is extra work for doctors, but gives reassurance to patients.

I always tell my patients that I will give treatment that is appropriate to their illnesses. But whether they can make a successful claim is between the patients and their insurers.

Desmond Wai (Dr)

Join ST's Telegram channel and get the latest breaking news delivered to you.