Insurance company refuses to pay, what can they do?

[rabiedabruce]

My neighbour's wife was diagnosed with cancer and their insurance company is refusing to pay for surgery even though they've been paying 60,000 baht for the past five years. Needless to say, they are extremely worried, the tumor is near her heart (no she's not Thai). I've advised they might try the Ombudsman here on Phuket, was I right? Good advert for self insurance I think, they would have 300k if they'd saved it themselves which would cover the cost of the op. Disgusting. Needless to say it's a Thai company.

[yeahbutif]

Be good to see what cover it says included or does not cover...

[ezzra]

First and foremost, have the urgent operation and save a life and then see a lawyer to read the policy very carefully and see if there a ground for a claim and if there is one, sue them.

Edited March 25, 2023 by ezzra

[zombie nights]

OP: can you please clearly state the reasons why the Insurance company are refusing to pay?

[scubascuba3]

Problem is most people don't read their insurance small print they only find out when claiming, but if you have a good case a lawyer can help you win in court, but takes many months, i know of one where the court case is 1 year+ later

[HampiK]

As you told it's a Thai insurer. I see some policy, they have a maximum amount for some diseases per lifetime. As long we do not know the policy we only can assume.
 

[4MyEgo]

26 minutes ago, scubascuba3 said:

but if you have a good case a lawyer can help you win in court

My wife told me that if you have money here, you can buy the other sides lawyer easily.

 

Now, let's take for example where we are, lawyer approaches insurance company and tells them his client is going to sue, insurance company says, Mr Lawyer, here is a brown envelope, now I'm sure there is more money in that envelope than your client will ever pay you.

 

Lawyer, yes Mr insurance company you are right, I will tell my client that it will take years and lots of money to get you to court and the probability of winning is low. 

 

It sounds far fetched, yes I know, but when my wife told me of a situation, it all made sense, but we all can believe what we want to believe, I just remember where we are and I know, money here comes before everything else.

[scubascuba3]

44 minutes ago, 4MyEgo said:

My wife told me that if you have money here, you can buy the other sides lawyer easily.

 

Now, let's take for example where we are, lawyer approaches insurance company and tells them his client is going to sue, insurance company says, Mr Lawyer, here is a brown envelope, now I'm sure there is more money in that envelope than your client will ever pay you.

 

Lawyer, yes Mr insurance company you are right, I will tell my client that it will take years and lots of money to get you to court and the probability of winning is low. 

 

It sounds far fetched, yes I know, but when my wife told me of a situation, it all made sense, but we all can believe what we want to believe, I just remember where we are and I know, money here comes before everything else.

Conspiracy theory. i hear about these cases all the time from my lawyer friend and it would go to court. Customer is paying the lawyer to work for them

[KhunLA]

Why I don't have, with few exceptions, as I've had to sue every insurance carrier when putting in a claim.

 

Not just Thailand, USA also, as very young friend of mine's policy wouldn't cover his 'terminal' cancer, after few years of premiums.   Luckily the test result were false, but certainly did open his eyes.

 

He's suing for all his premiums he paid, and then some.

[Etaoin Shrdlu]

Why is the insurance company denying the claim?

 

First stop in a dispute with a Thai insurer should be to the Office of the Insurance Commissioner. https://www.oic.or.th/en/consumer

 

You will need someone who speaks Thai to help you. You will get a fair hearing from the OIC.

[watchcat]

1 hour ago, scubascuba3 said:

Problem is most people don't read their insurance small print

That's the whole point why they (insurance companies) make it it in small print.  I've never used them and never will.

[rabiedabruce]

2 hours ago, ezzra said:

First and foremost, have the urgent operation and save a life and then see a lawyer to read the policy very carefully and see if there a ground for a claim and if there is one, sue them.

In my experience, they check the insurance will pay before administering any treatment.

[rabiedabruce]

1 hour ago, Etaoin Shrdlu said:

Why is the insurance company denying the claim?

 

First stop in a dispute with a Thai insurer should be to the Office of the Insurance Commissioner. https://www.oic.or.th/en/consumer

 

You will need someone who speaks Thai to help you. You will get a fair hearing from the OIC.

Thanks for this, the husband is Thai so he will understand it. I'll pass it on.

[rabiedabruce]

1 hour ago, scubascuba3 said:

Conspiracy theory. i hear about these cases all the time from my lawyer friend and it would go to court. Customer is paying the lawyer to work for them

Not a 'conspiracy theory', one of my lawyers ended up dumping me and working for my opponent. Another was bribed to try to persuade me to drop the case. Lawyers have no integrity here and most want 300k as soon as you walk in the door. Ever been to Phuket?

[rabiedabruce]

2 hours ago, HampiK said:

As you told it's a Thai insurer. I see some policy, they have a maximum amount for some diseases per lifetime. As long we do not know the policy we only can assume.
 

You'd think it would cover bloody cancer at 60k per year ..

[rabiedabruce]

2 hours ago, zombie nights said:

OP: can you please clearly state the reasons why the Insurance company are refusing to pay?

How about 'because we've 'ad your money'? I've no idea. The wife's pretty smart and would've checked the policy. I'll ask when I next see him. I merely posted to see what action they could take as they're talking about having the op done in a clean professional 'don't treat you like a child' Malaysia for half the price. Very unfair if they've already paid. Imo, Thai hospitals are arrogant and greedy.

[rabiedabruce]

2 hours ago, zombie nights said:

OP: can you please clearly state the reasons why the Insurance company are refusing to pay?

No. Should have asked, but don't want to appear too intrusive.

[NoshowJones]

51 minutes ago, watchcat said:

That's the whole point why they (insurance companies) make it it in small print.  I've never used them and never will.

All that fine print and legal jargon is there to try and help them refuse claims. small print should be made illegal on anything. There is no reason for any small print, apart from hoping that people won't notice it.

[Liverpool Lou]

4 hours ago, rabiedabruce said:

Disgusting.  Needless to say it's a Thai company.

Depends on the reason for the claim being denied, it wouldn't be "disgusting" if it wasn't covered by the policy.

 

"Needless to say it's a Thai company".

Needless to say many people don't read what their cover extends to.

Edited March 25, 2023 by Liverpool Lou

[Liverpool Lou]

1 hour ago, watchcat said:

they (insurance companies) make it it in small print.  

No, they do not, "small print" is a myth, policies do have easily read conditions, though, that some people don't bother to read and when a claim is legally denied (because it wasn't covered from the start) the claimants call it "small print".

[Liverpool Lou]

1 hour ago, rabiedabruce said:

You'd think it would cover bloody cancer at 60k per year ..

No, any reasonable person would think that cancer would be covered only if it was bloody specified in the policy.

[Liverpool Lou]

1 hour ago, rabiedabruce said:

4 hours ago, zombie nights said:

OP: can you please clearly state the reasons why the Insurance company are refusing to pay?

How about 'because we've 'ad your money'?

Such nonsense.  How about because there were exclusions in the policy that "she read"?

[Liverpool Lou]

1 hour ago, rabiedabruce said:

4 hours ago, zombie nights said:

OP: can you please clearly state the reasons why the Insurance company are refusing to pay?

No. Should have asked, but don't want to appear too intrusive.

So you have no idea why the claim was denied so you just choose to irrationally slag-off the insurer?  

[jerrymahoney]

This is the first step on  the Thailand Office of Insurance Commission (OIC) Complaint portal:

 

https://complaintportal.oic.or.th/ppms/login

[Liverpool Lou]

1 hour ago, NoshowJones said:

All that fine print and legal jargon is there to try and help them refuse claims. small print should be made illegal on anything.

It is illegal and. consequently, there is no "small print" in insurance policies, only policy conditions that anyone can read.

[spidermike007]

Most insurance companies are like mafia organizations. They do nearly everything they can, to deny claims. That is where the real money is. 

 

I despise them, and self insure as much as I can. 

[Eloquent pilgrim]

Firstly, very sorry to hear about the woman’s diagnosis, I can only start to imagine how traumatic it must be.

 

However, OP, you really haven’t given enough information for anyone to be able to offer any sensible advice. The really obvious thing that anyone needs to know in order to offer advice is, what reason have the insurance company give for refusing to cover the surgery. Without knowing that, you will get plenty of sympathy but not much credible advice.

[scubascuba3]

3 hours ago, rabiedabruce said:

Not a 'conspiracy theory', one of my lawyers ended up dumping me and working for my opponent. Another was bribed to try to persuade me to drop the case. Lawyers have no integrity here and most want 300k as soon as you walk in the door. Ever been to Phuket?

Don't use a lawyer then and their claim denied was successful again, with high 5s all round the office

[Sheryl]

1 hour ago, jerrymahoney said:

This is the first step on  the Thailand Office of Insurance Commission (OIC) Complaint portal:

 

https://complaintportal.oic.or.th/ppms/login

This.

 

Easy to do online

 

No need for  lawyer.

 

 

 

 

[Sheryl]

P.S. the above applies only if it is a Thai-issued policy.

 

If foreign issued  then consult the policy dicuments which  will describe appeals procedure.