How to understand the coverage of my health insurance in Thailand correctly?

[Felt 35]

I have an affordable health insurance in Thailand with a well known company often mentioned regarding insurance in this forum. 

It have a maximum limit per disability per policy year
set as Thb 1,200,000.
Hospital Expenses set as Thb 200,000,-
Surgical Fee included pre-surgical assessment  set as Thb 200,000,-
plus all the other things set with different covers as room and board, intensive care, specialist consulatation fee, emergency OPD etc, etc,...

 

Now, I had an accident a few months ago. Post traumatic pain have made it clear that I need a surgery and have been offered some surgery package's at a couple of hosptals in the range of Thb 300,000 - 400,000,- 

Will this insurance cover? I was hoping so due to a maximum limit on 1,200,000,- My Thai wife believe different because the Hospital expenses are set as Thb 200,000,-

I have had this insurance some years and thankfully never needed it so have no previous claims. However I don't think its smart to ask the insurance company the above question because of eventually later exclusions even if I not use the insurance in this case, i.e. regarding further policies.

 

Thanks

Felt 

 

[KhunLA]

Seems your wife is correct, I think.  Hope it wasn't expensive, as you found out, 200k doesn't cover much.

 

Why I'm a bit Anti-insurance.

[Etaoin Shrdlu]

You will need to look into the details of the package the hospital is offering and get them to unbundle them for insurance claim purposes. How much of their package is comprised of surgical fees, how much is room and board, how much is hospital supplies, etc. The individual components of the "package" may be within the policy's internal limits.

 

I would suggest you look at the policy to see what approvals you need to obtain prior to having the procedure done and get the insurer's sign-off as well as a clear understanding of how much of the cost will be covered.

 

If you used a broker, ask your broker to assist.

 

 

[scubascuba3]

Let us know the outcome, i like to hear what insurers do in the event of a claim 

[cnx1204]

Did you have the hospital look at your policy and give you their interpretation?  How would they bill, the company or you?  If the company, they may have experience with that company and know how to bill to get the maximum reimbursement for their patient.

[internationalism]

that 1.2mln looks like pacific cross.

your surgery has to be pre-approved. So you need written quotation from hospitals and forward them to insurer. Based on different quotations insurer can re-negotiate price directly with hospital. They might tell you which hospital they approve. 

Those 300-400k looks more like private hospitals. 

Look into the governmental hospitals quotations, possibly they would be below 200k for operation itself, lower for hospital, bed and no co-pay.

Yes, for large claims the PC will rise your yearly contribution by 25% for the next 2 years. But they can't exclude pain from future. Clearly it's not pre-existing.

Definitely you should not hesitate to claim it. That's why you have this policy. You have already payed them hundreds of thousands over years.

 

You had a chance to claim accident on your policy (unless you have deductible above that). Probably too late now (usually 1 month for application), but not harm to ask. 

If you have indeed pacific cross, you might think of upgrading accident when re-newing from their 150k included in your plan up to 1mln. That is fairly cheap, only 150b for addiction 100k cover. Again, it works only above deductible, but in my opinion worth. 

[Liverpool Lou]

Impossible for anyone to know without seeing the actual policy wording unless you have posted it exactly word for word in your OP and with all the associated context.    Are the policy conditions only in Thai?  If they're in English, don't take your wife's word for it, with all due respect, she is not the insurer.

 

You mentioned having an accident, is it a health insurance policy or an accident insurance policy?

 

Why would you not want to ask the insurer (as they're the ones that will make the decision)?  They cannot alter the policy conditions to deny cover, as you seem to be suggesting, just because you've asked them questions about the cover that they are contracted to provide.  

 

 

[scubascuba3]

57 minutes ago, internationalism said:

 

You had a chance to claim accident on your policy (unless you have deductible above that). Probably too late now (usually 1 month for application),

Could be even within 24 hours, that's what Axa requires

[Felt 35]

Thank you all very much for your information.

Below package price from one private hospital

 

Package Price (Baht)

Arthroscopic -------------------- repair, based-GP,  Thb 310,000
Pre-op                                                                        Thb   10,000
Specific Instruments                                                 Thb    91,000
Accessory items                                                        Thb       9,000
Home med                                                                 Thb      5,000

Two nights single room                                             Thb     (price not specified)

Total                                                                            Thb   425,000

 

 

Roughly Insurance cover

No Limit on Hospital Choices

Anaesthetist’s Fee Included in Hospital Expenses

Surgical Fee Including Pre-Surgical Assessment and
Normal Post-Surgical Care (Actual Expenses)

200,000

Hospital Expenses : Diagnostic Laboratory Fee, X-rays, Prescribed
Medicines, Blood and Plasma, Wheel Chair Rentals, Surgical Appliances

200,000

Operating Theatre Included in Hospital Expenses

Room and Board, Nursing Charge, Other Medical Charge
(Maximum limit per day) 5,000

Thanks, Felt

 

 

 

[Jerno]

First and most important understanding about Insurance companies is they will deny payment or coverage for any possible reason.  They are not your friend, not looking out for your best interests, don't care about you unless you miss paying premiums, then quickly use that to deny you any coverage. They are there to make money, and less payouts, more money they make. Use them but don't trust them.