So, I have a perfectly valid claim which was confirmed by agent and hospital, but insurance is refusing the claim. It's not a lot of money (between 15k and 20k baht) and I will pay it myself, but it does make me wonder about any future valid claims especially if there is something serious. 

 

When I'm back in Canada behind the safety of my IP wall I'll name them.

 

 

 

Can you say what the claim was for and what reason was given to deny payment?

 

The claim was colonoscopy. The reason given is completely unrelated and nonsensical which has nothing to do with pre existing condition. 

 

They also previously refused me another perfectly valid claim from medpark.

 

To be fair I think people who have health insurance that is not based in Thailand perhaps have better luck.

 

Thai insurance is just a scam.

 

 

I have had health insurance for years in Thailand.  The bulk of the coverage kicks in only if I am admitted(IPD-Inpatient).  I have very little OPD-Out Patient coverage.  A few months ago I had a combined Endoscopy/Colonoscopy done.  It was as an outpatient so no coverage under IPD.  In the end I paid 39,00 Baht.  This amount was much less than in the USA.  

 

As always the "devil is in the details". 

In Thailand it is always wise to clear it up with the insurance company whether the'll pay for it or not, I know, you have insurance or  you THOUGHT you were covered but guess what? surprise surprise...

3 minutes ago, ezzra said:

In Thailand it is always wise to clear it up with the insurance company whether the'll pay for it or not, I know, you have insurance or  you THOUGHT you were covered but guess what? surprise surprise...

Actually I did confirm it hence the post.

 

And to be honest I was totally expecting this even though  the hospital and agent confirmed the claim as valid.

Most people are happy with thai insurance but then again they haven't tried to claim...

This is one of the reasons that many expats refuse to take out Thais health insurance and prefer auto-insurance while gradually saving unnecessary insurance premiums for the future health problems.

 

The latest Thai insurance scandal with Covid policies is a clear example.

 

 

Don't be fooled into thinking Insurance companies are there to help you.  They are there to pay out the fewest claims possible.  Every payout is reduced profit for them.

55 minutes ago, Pravda said:

The claim was colonoscopy. The reason given is completely unrelated and nonsensical which has nothing to do with pre existing condition. 

 

They also previously refused me another perfectly valid claim from medpark.

 

To be fair I think people who have health insurance that is not based in Thailand perhaps have better luck.

 

Thai insurance is just a scam.

 

 

Fully agree,but colonoscopy ain't exactly medical emergency,just routine health checking. Try India couple of hours away nearest point,what you were quoted could be had for 500 baht couple of years ago(covid)  prob now around 800 baht...borders opening up

53 minutes ago, BE88 said:

This is one of the reasons that many expats refuse to take out Thais health insurance and prefer auto-insurance while gradually saving unnecessary insurance premiums for the future health problems

Yes, I'm one  of those. Age and pre-existing conditions disqualify me anyway, but my view was coloured a good few years ago by a casual acquaintance who came into the bar one day with a foot heavily bandaged. He was coming to say goodbye, he was going back to England, having spent all his resources on an operation to remove a big toe which had turned septic, caused by diabetes, and would probably require further surgery. His insurance company refused to cover his costs because he had not declared a pre-existing condition. "I paid in to them for years and years," he said, "I never knew I had diabetes."

Many medical insurance policies don't cover routine screenings or check-ups. Under such policies there would have to be a medically necessary reason to perform a colonoscopy for cover to apply and would likely require prior written approval from the insurer based upon a doctor's report.   Your policy should explain when approval is needed and how to obtain it. What does your policy say?

 

 

 

 

 

42 minutes ago, Eff1n2ret said:

Yes, I'm one  of those. Age and pre-existing conditions disqualify me anyway, but my view was coloured a good few years ago by a casual acquaintance who came into the bar one day with a foot heavily bandaged. He was coming to say goodbye, he was going back to England, having spent all his resources on an operation to remove a big toe which had turned septic, caused by diabetes, and would probably require further surgery. His insurance company refused to cover his costs because he had not declared a pre-existing condition. "I paid in to them for years and years," he said, "I never knew I had diabetes."

A good friend of mine, in his mid-fifties, didn't know he was diabetic until I pointed out that stopping at a gas station every 30 or 40 minutes for a pee during a 4-hour interstate drive in the US was not normal. He had already accepted the need for an afternoon nap in his office after lunch was also normal.

 

As we live beyond 55 or 60, getting an annual medical assessment is a wise investment. I suggest starting the whole self-review mid-way or 6-months before your next insurance renewal. If you are starting on such a regimen, spend the first 3 months doing moderate exercise along with a review of your dietary intake including alcohol. Again, the word is moderation. Then do the medical assessment 3 months before your insurance renewal. This may (or may not) afford you sufficient time to take care of anything that crops up before paying for another year of coverage and keeps you fully aware of what is changing as you age.

 

To assume that the natural health impingement your advancing years will happily be accepted by your insurer is a dangerous one.

51 minutes ago, Etaoin Shrdlu said:

Many medical insurance policies don't cover routine screenings or check-ups. Under such policies there would have to be a medically necessary reason to perform a colonoscopy for cover to apply and would likely require prior written approval from the insurer based upon a doctor's report.   Your policy should explain when approval is needed and how to obtain it. What does your policy say?

 

Precisely. Make the effort to self-fund your own, annual health checkups and be one step ahead of your insurer if/when a medical emergency or intervention pops up.

20 minutes ago, NanLaew said:

Precisely. Make the effort to self-fund your own, annual health checkups and be one step ahead of your insurer if/when a medical emergency or intervention pops up.

They could still say something is an undiagnosed pre-existing condition and not cover a claim. Maybe you've seen a doc showing how they decide this?

35 minutes ago, scubascuba3 said:

They could still say something is an undiagnosed pre-existing condition and not cover a claim. Maybe you've seen a doc showing how they decide this?

The policy will state the definition of pre-existing condition. Usual definition is a condition that was known, or could reasonably have been known, at the time the policy was taken out.

 

If undiagnosed conditions could all be subsequently excluded even if no way the insured could have known of them then all cancers, most heart conditions, most spinal problems etc would never be covered. In fact they usually are.

 

International Insurers who do full medical underwriting will specify in the policy what conditions are excluded and unless there was some falsification on the application nothing else will be subsequently excluded.  The more professional Thai insurers, likewise, but unfortunately many fall far short of that descriptor. Another reason I always advise people to take out internationally issued, not Thai-issued policy where possible.

 

That said, if a Thai insurer  tries to deny something on grounds of pre-existing condition when in fact there was no way the insured could reasonably have known of the condition at time of application, it can be appealed to the OIC. That process is nto difficult and can be initiated online. However in my years on this board I find that people who complain that something has unfairly been denied, when told how to appeal, usually fail to follow up which makes one wonder what the real situation was.

 

These issues most often arise when claim is made in the first year or two of taking out a policy.  especially the first year, as insurers are alertt to the possibility that someone may have taken out a policy specifically to cover a problem they already knew they had.  Also arise more often with Thai based companies than international ones, and some companies are worse in this regard than others.

 

I just went through insurance pre-approval process for surgery for a spinal condition on a policy I took out in 2018.  I had no prior spinal problems that I knew of and symptoms began only in July 2021. However this type of spinal problem develops gradually over many years, so I was concerned as to how it would be handled.

 

Approved with no issues. The policy is issued from an EU country with full medical underwriting.

 

 

 

 

 

 

 

 

 

 

3 hours ago, BE88 said:

This is one of the reasons that many expats refuse to take out Thais health insurance and prefer auto-insurance while gradually saving unnecessary insurance premiums for the future health problems.

 

The latest Thai insurance scandal with Covid policies is a clear example.

 

 

Auto-insurance?

3 hours ago, Jerno said:

Don't be fooled into thinking Insurance companies are there to help you.  They are there to pay out the fewest claims possible.  Every payout is reduced profit for them.

 

The problem is fraud, cheating and theft.

 

We all know this to be true. Why would you even argue against it?

I have an excellent policy from a Thai Insurer. They paid a massive bill 15 months ago without any delay.

 

This particular Thai insurer issues insurance contracts only in Thai. Not unusual for a Thai insurer in Thailand I'm sure.

2 minutes ago, blackprince said:

I have an excellent policy from a Thai Insurer. They paid a massive bill 15 months ago without any delay.

 

This particular Thai insurer issues insurance contracts only in Thai. Not unusual for a Thai insurer in Thailand I'm sure.

Well, why not name them here then? 

4 hours ago, Pravda said:

I have a perfectly valid claim which was confirmed by agent and hospital, but insurance is refusing the claim.

Neither the agent not the hospital decides on the validity of a medical insurance claim, only the insurer does that, perhaps your claim was not, in fact, valid?   Just because you say that it was legitimate, with no details, doesn't make it so, neither does it make "medical insurance in general a scam". 

3 minutes ago, Chris.B said:

Well, why not name them here then? 

I subscribed to the offer 15 years ago. The application period lasted for 6 months.

 

I'm a bit suprised you don't see fit to answer the OP the same question.

 

If you're scared of the libel laws here, you could PM him/her.

4 hours ago, Pravda said:

The claim was colonoscopy. The reason given is completely unrelated and nonsensical which has nothing to do with pre existing condition. 

What was the reason for denying your claim?  What you posted there is not an insurer's reason for doing so, neither is it how an insurer would explain the reason!

4 hours ago, Pravda said:

Thai insurance is just a scam.

Completely untrue and how this misleading thread is allowed to continue is unbelievable.

3 hours ago, Pravda said:

Actually I did confirm it hence the post.

 

And to be honest I was totally expecting this even though  the hospital and agent confirmed the claim as valid.

wot Sheyrl says .

8 minutes ago, Liverpool Lou said:

Completely untrue and how this misleading thread is allowed to continue is unbelievable.

"Scam" is an inflammatory term but is OP's interpretation of what happened. He is entitled to his view. He has stated the facts in the thread.

3 hours ago, Pravda said:

And to be honest I was totally expecting this even though  the hospital and agent confirmed the claim as valid.

Were the agent and the hospital underwriting the policy?  If not, their opinion would be irrelevant.

OP: assuming this was a Thai insurer you can appeal to the OIC.

 

You can do it online, here is the link:

https://www.oic.or.th/en/home

Click on consumer>questions and complains>complaints

Use chrome or other browser that provides translation as once you get to the complaint forms they are in Thai

 

You can also call them at Tel.0-2515-3999 best to have a Thai speaker assist you

Contrary to what some assume the OIC is an independent regulatory body and they can and will take action if an insurance company does not honor the terms of the insurance policy

 

If it was NOT a Thai;and-based  insurer, but rather an insurer based elsewhere who covered you in Thailand, then (1) your thread title is seriously misleading  and (2) you can appeal it following whatever procedure is laid out in your policy.

 

Do NOT come back and name the insurer in this thread later, even when abroad, we would have to remove that in keeping with rules on defamation. You might feel secure being out of Thailand but the forum is not.

 

By the way, is your policy inpatient only and might the issue revolve around what is considered a "day surgery"? Was pre-approval required and if so, did you get it?

8 minutes ago, blackprince said:

I subscribed to the offer 15 years ago. The application period lasted for 6 months.

 

I'm a bit suprised you don't see fit to answer the OP the same question.

 

If you're scared of the libel laws here, you could PM him/her.

OP said they were scared of naming and shaming the company until they leave the country.  But if someone has only good experiences with a local insurance company it would be nice if they could name them.  Relying on insurance for health emergencies is a big risk but also very important.  If you were looking for a new insurance company and you came across a post like yours that was a year old and perhaps from a now-inactive account, you too would wish they named the insurance company they spoke so highly of.

50 minutes ago, properperson said:

It's a legal document, so you always have the option of taking the insurer to court ....

 

It is indeed a legal contract but he hardly needs to go to court.

 

He just needs to file a complaint with the OIC (assuming it is a Thai company).

 

In my experience just doing that will often result in the company paying at once. Though of course it does depend on the circumstances.

 

OP should be aware that sometimes problems arise because of poor or insufficient documentation by the hospital, Thai hospitals can be very poor at that. When asked for more information by the insurance company  (as commonly happens) rather than provide it some simply tell the patient the insurer did not pay in order to save themselves work. Do not fall for that and do nto pay until/unless you have clear indication this was not the issue.

 

If Broker (Agent) is any good they would contact the insurer, find out exactly what the situation is and why not paid, and let you know.