Complaints about Unsuccessful Medical Insurance Claims

Ms Carrie Tan asked the Prime Minister (a) whether MAS monitors the annual number of complaints brought by citizens through the relevant channels regarding unsuccessful claims for medical insurance; (b) if so, what percentage of these complaints arise from claims rejected by insurers citing non-declaration of relevant health information; and (c) whether there are data or studies that show the typical number of such incidents reported and what is the probable number of unreported cases.

MAS expects insurers to be fair and reasonable to all policyholders, including not rejecting health insurance claims on the basis of undeclared minor and unrelated conditions. MAS closely monitors the trends for complaints lodged with MAS.

In the past three years, about 20% of health-insurance related complaints made to MAS were due to unsuccessful insurance claims. Of these complaints relating to unsuccessful claims, the majority was concerned with treatments not being covered under the insurance contract, claims that exceeded claim limits or were made after the policy had lapsed, or failure to submit supporting documents required by insurers to assess the claim application. Less than 5% of health-insurance related complaints received by MAS over the period pertained to unsuccessful claims due to non-disclosure of health conditions.

To reject a claim on grounds of non-disclosure of health conditions, insurers must demonstrate that the non-disclosure is material to the underwriting outcome and that the applicant could be reasonably expected to have disclosed the information during the application for the policy.

Policyholders who feel their claims have been unfairly rejected and are unable to reach a satisfactory resolution with the insurer may file a claim for mediation or adjudication at the Financial Industry Disputes Resolution Centre (FIDReC). MOH has also established a Clinical Claims Resolution Process (CCRP) for Integrated Shield Plan claim disputes of a clinical nature, such as whether claims were unfairly rejected for medically appropriate treatment or procedures, or whether there was over-charging or over-servicing by medical practitioners.