SINGAPORE - All Integrated Shield Plan (IP) insurers will provide coverage of diagnostic endoscopy - a common procedure that allows doctors to look inside a patient's body and detect diseases - which are medically necessary, clarified the Life Insurance Association, Singapore (LIA) in a statement on Friday (Sept 4).
This comes after the Singapore Medical Association (SMA) in an Aug 29 letter in The Straits Times Forum section said that some insurers are no longer allowing claims for diagnostic endoscopies even when they are medically required. It prompted an outcry among specialists.
LIA's Friday announcement means these insurers will no longer be disallowing claims for the procedure, when it is medically necessary, and regardless of the outcome of the procedure.
The insurance association said in its statement that "among the seven IP insurers, only one insurer previously had stricter claim rules in relation to gastrointestinal endoscopy, consistent with their policy terms and conditions".
The insurer has "since aligned its practices with prevailing industry norms and policyholders can be assured that their medically necessary diagnostic endoscopies will be covered by all IP insurers", it added.
This insurer is Aviva. When contacted, its spokesman said that the firm started in March this year to take "a stricter stance in claims assessment towards a small number of claims for standalone endoscopies that were not associated with in-patient treatment or hospitalisation". This is in line with their policy terms, he said.
"We reviewed this practice in August and subsequently decided to approve claims for endoscopies because they are day surgical operations, even if they do not lead to in-patient treatment or hospitalisation," said the Aviva spokesman.
"We had already started approving new claims for standalone endoscopies in August, and will be initiating revised claim settlements for such endoscopy claims that were previously rejected."
In SMA's letter earlier, no insurers were named.
Doctors ST spoke to said that some affected patients have had to pay out of their own pocket and some had said no to the procedure even though this may cause a delay in diagnosis and the worsening of the patients' condition. Patients were upset, as they were caught unaware by the change, they said.
Dr Ng Chee Kwan, SMA's first vice-president, who signed off the SMA letter, said that until early this year, all insurance companies would cover the costs of diagnostic endoscopies for their IP clients as part of their coverage for all day operations and hospital admissions.
"It was early this year that an insurance company decided not to cover diagnostic endoscopy," he said.
SMA's letter was written with the support of the Society of Colorectal Surgeons (Singapore).
The society's president, colorectal surgeon Ng Chee Yung, said: "I noticed from the beginning of the year, some insurers started to either categorically stop coverage or started a process of their own vetting - through pre-authorisation - that would question the specialist's indication for the procedure and ultimately deny the coverage in many instances.
"Most scopes are not of dire urgency, which is why typically there is time for a pre-authorisation process for the insurers to intervene and 'block' such procedures."
Dr Ng said a typical case that might get rejected could be a case where someone was suffering from abdominal symptoms but denied an endoscopy claim on the basis that the endoscopy is "diagnostic".
"Quite a large number of patients have been affected. Sometimes, with much to-ing and fro-ing of e-mail justifications and rebuttals (over claim approvals)," said the society president.
"However, this takes a very significant effort on the doctors' part and to do it routinely for every case would be too great a burden to be practical for the doctor."
Gastroenterologist Desmond Wai, whose clinic is at Mount Elizabeth Novena Specialist Centre, said he started to receive requests from patients to write memos on the reasons for the endoscopy procedures done since earlier this year.
Some of his patients have said that they will not go ahead with the procedure as they cannot claim for it.
Dr Lim Ing Ruen, a ear, nose and throat surgeon who has a clinic at Mount Elizabeth Medical Centre, said doctors were shocked to hear of the move to disallow claims as patients usually go to specialists for an unresolved issue and would be expecting a more thorough examination.
A patient with a unilaterally blocked ear, for instance, may commonly find that he has an infection, but there is a chance that the blockage is due to an early tumour.
The latter can be picked up by an endoscopy, and will be missed if the procedure is not done and the blockage simply treated with steroids instead. It will result in a delayed diagnosis of the problem. "In fact, it's not ethical," she said.
Endoscopies are commonly carried out on a daily basis to rule out more serious problems. In such procedures, a long, thin and flexible tube with a light and a camera, called an endoscope, is inserted into the body for a look inside. It is used to examine many parts of the body, including the stomach and duodenum, colon and rectum, nasal passages and bladder.
The cost of diagnostic endoscopy varies - there are different types - and may range from below $500 to $3,000 and above.
"In general, doctors would recommend that their patients undergo diagnostic endoscopy if the patients need to be evaluated for a serious underlying condition such as an ulcer or cancer," said SMA's Dr Ng.
It is the only reliable way of detecting some of the more common cancers in Singapore, such as colorectal cancer, gastric cancer, nasopharygeal cancer and bladder cancer, he said.
Ms Pauline Lim, LIA's executive director, told ST: "IP insurers will review the clause within IP contracts on diagnostics, and, where relevant, issue clarifications so that the intent that diagnostics which are medically necessary will be covered, regardless of the report results, is made clearer."
Gastrointestinal endoscopies are among the most common procedures seen in IP claims.
LIA's Friday statement said that in general, a procedure is considered medically necessary when the patient has symptoms indicative of a medical condition, and the procedure is consistent with the customary management of the medical condition.
Those who are well and undergo gastrointestinal endoscopy for screening purposes would not be able to make a claim, it said, as IP plans do not cover health screening.
The association and IP insurers emphasise that IPs do cover surgical procedures done in a day surgery centre and private clinics so long as they are claimable under MediShield Life, and that hospitalisation is not required for such procedures to be claimable.
"However, if the patient's medical condition is one that can be treated in an outpatient, or day surgery, setting but the patient chooses to be admitted to the hospital for the procedure, the insurer would not be able to cover the room and board, (as well as) other incremental charges arising from the hospitalisation," it said.
This is because, in such a scenario, the hospitalisation would not be medically necessary, it explained.
In its statement, LIA advised policyholders to make use of their IP insurer's pre-authorisation service, if available, to confirm coverage before undergoing a planned day surgery or hospitalisation.