Insurancce question

[Larryst]

I know a guy that got a policy with a Thai insurance company. They have a 6 months grace period. Where anything comes up is preexisting problem. He had the policy for 4 months and had a heart problem. Went to Bangkok Pattaya Hospital diagnosed with heart problem. Not covered under the policy (preexisting). Can he try other insurance companies in Thailand so he can get covered? Do all insurance check at all hospitals? Or is he not insurable and has to cover hospital bills out of his own pocket?

[scubascuba3]

It's a pre-existing condition, not covered, get the wallet out

[Etaoin Shrdlu]

His heart condition will be considered a pre-existing condition by almost any insurer, Thai or foreign, and therefore will be excluded from coverage.

 

If he fails to declare a known pre-existing condition when applying for insurance, this could be grounds for the insurer to deny the claim in question, cancel the policy from inception and require the repayment of any claims that had been made previously.

 

Thai insurers usually don't contact hospitals for underwriting information at the time the proposer submits an application, but they almost always do if and when a significant claim is submitted, especially if the claim is related to something that could be a pre-existing condition.

[Lorry]

1 hour ago, Etaoin Shrdlu said:

His heart condition will be considered a pre-existing condition by almost any insurer, Thai or foreign, and therefore will be excluded from coverage.

Some insurers do cover preexisting conditions if this condition hasn't caused any claims or any necessary treatment (depending on the insurer) for the first years of insurance (may be 2 or 3 years). It's called a moratorium.

I am not up to date which insurers do this,  it changes too often. 

 

Obviously, not all insurers from all over the world call all hospitals worldwide, but for practical purposes,  yes, they call all relevant hospitals. And then,  what happens has just been posted:

 

1 hour ago, Etaoin Shrdlu said:

If he fails to declare a known pre-existing condition when applying for insurance, this could be grounds for the insurer to deny the claim in question, cancel the policy from inception and require the repayment of any claims that had been made previously.

 

 

[Sheryl]

14 hours ago, Lorry said:

Some insurers do cover preexisting conditions if this condition hasn't caused any claims or any necessary treatment (depending on the insurer) for the first years of insurance (may be 2 or 3 years). It's called a moratorium.

I am not up to date which insurers do this,  it changes too often. 

 

 

Any necessary treatment includes any related medication. Which someone hospitalized for a heart condition would likely have.

 

Usual moratorium perriods seem to be 2 years.

 

If OP's friend is able to get an insurance policy at all. It would almost certainlh contain a broad exclusion for cardoovascular diseases. 

[J Branche]

I talked to AAinsure after submitting my first claim recently.  They said after 1st claim insurance with PC they will ask at hospital you submit bill from, any hospital you fill in that you have visited recently.  If you say none insurance will check with 2 random, additional surrounding hospital and inquire if you have Any medical history with those hospitals.

 

Additionally insurance with cherry pick information and manipulate it to attempt Not to pay.  Consult with the doctor before answering follow up questions from insurance.  My insurance asked questions about some info that has never been tested or verified.  Hospital had somehow written info from another patient on my record.

[Liverpool Lou]

On 8/31/2024 at 8:47 AM, Larryst said:

Went to Bangkok Pattaya Hospital diagnosed with heart problem. Not covered under the policy (preexisting). Can he try other insurance companies in Thailand so he can get covered?

He will have to declare his pre-existing condition and possibly answer the question of whether he has ever had a policy or claim denied.  If he isn't truthful, he may as well not bother with the cover because his lies will probably be uncovered, voiding his policy.

[Etaoin Shrdlu]

2 hours ago, J Branche said:

I talked to AAinsure after submitting my first claim recently.  They said after 1st claim insurance with PC they will ask at hospital you submit bill from, any hospital you fill in that you have visited recently.  If you say none insurance will check with 2 random, additional surrounding hospital and inquire if you have Any medical history with those hospitals.

 

Additionally insurance with cherry pick information and manipulate it to attempt Not to pay.  Consult with the doctor before answering follow up questions from insurance.  My insurance asked questions about some info that has never been tested or verified.  Hospital had somehow written info from another patient on my record.

 

It seems to be common practice for Thai insurers (and many non-Thai insurers) to accept an application for medical insurance and to then issue a policy without requiring the applicant to submit comprehensive medical records. The insurers simply rely upon the applicant to disclose what he or she may recall or may understand about their medical history. While this is very convenient for both parties at that time, it is a potential trap for the applicant and a potential get-out-of-jail-free card for the insurer.

 

Lurking within all the lab reports and doctors' notes in one's medical files may be conditions that have not been revealed to or discussed with the patient. Some insurers will consider lab results that are below the level that indicates clinical disease to be sufficient to trigger a pre-existing condition exclusion. There may be doctors' notes referring to issues that weren't the purpose of the particular investigation that weren't mentioned to the patient at the time. One can also simply forget things that don't seem important at the time.

 

If someone is really serious about avoiding non-disclosure issues, then it may be advisable to submit actual medical records going back as far as possible along with the application for insurance and to let the insurer go through them at the time of first application. While this may increase one's chances of having more conditions excluded, or denied cover due to uninsurability, this is still preferable to having cover for a large claim denied and policy cancelled from inception after having paid a couple of years' premiums to the insurer and believing that cover was reliable when in fact it wasn't.

 

 

 

[richard_smith237]

2 minutes ago, Etaoin Shrdlu said:

The insurers simply rely upon the applicant to disclose what he or she may recall or may understand about their medical history. While this is very convenient for both parties at that time, it is a potential trap for the applicant and a potential get-out-of-jail-free card for the insurer.

 

Indeed...   After initially agreeing pre-authorising a procedure, payment was later rejected by my insurance company because there was a 5 year moratorium (on Renal issues)... 

 

Even though the procedure was more than 5 years after I'd had a kidney stone, insurance refused to pay up, because in my medical notes, from a routine medical check up (about) 4.5 years before hand there was a comment that 'no evidence or previous stone in left kidney' (or words to that effect). 

... The insurance claimed this was a pre-existing condition that fell within the moratorium - I countered that a comment referring to the 'absense' of a condition is not the condition itself, however, they continued to object to my claim. 

 

I ended up paying the 130,000 baht myself a few months later as the hospital started putting pressure on me to pay out (letters suggesting they would take legal action if I didn't pay).

 

 

 

 

 

[Etaoin Shrdlu]

2 minutes ago, richard_smith237 said:

 

Indeed...   After initially agreeing pre-authorising a procedure, payment was later rejected by my insurance company because there was a 5 year moratorium (on Renal issues)... 

 

Even though the procedure was more than 5 years after I'd had a kidney stone, insurance refused to pay up, because in my medical notes, from a routine medical check up (about) 4.5 years before hand there was a comment that 'no evidence or previous stone in left kidney' (or words to that effect). 

... The insurance claimed this was a pre-existing condition that fell within the moratorium - I countered that a comment referring to the 'absense' of a condition is not the condition itself, however, they continued to object to my claim. 

 

I ended up paying the 130,000 baht myself a few months later as the hospital started putting pressure on me to pay out (letters suggesting they would take legal action if I didn't pay).

 

 

 

 

 

 

If the policy contained wording that imposed the moratorium when it was issued,  there probably wasn't much you could have done about this. If this is the case, then It seems that the insurer got ahead of itself in authorizing payment before reviewing the policy.

 

If the insurer sought additional medical records when the claim was submitted and this is how the condition was discovered, you're probably out of luck based upon non-disclosure. But if the policy was issued without moratorium wording and the doctors' notes were disclosed at the time of application, then you may have reason to visit the OIC and seek relief.

 

There is also a five-year time bar for obtaining additional underwriting information prescribed by the Thai Civil and Commercial Code that applies from the time the first policy incepted, but not the time the condition was discovered or treated.

 

If one is able to have five years' continuous cover from the same insurer, the insurer then can't go back and request additional medical information, making it much more difficult for them to cite non-disclosure and deny a claim. It does not sound as if this would have helped in your case, unfortunately.

[Larryst]

Here's the whole story on what happened. The guy had insurance about 2 years. He bought the cheapest plan they had. He then had a motorbike accident last February. Everyone told him most insurance companies won't pay or hardly anything on motorbike accidents. He got mad because they wouldn't pay. I told him to upgrade his policy to a better plan. Instead he switched isurance company for a different plan. 4 months later he went to Bangkok Pattaya Hospital with heart problem. New insurance company told him preexisting condition. Now has to pay out of his own pocket. Knowing him. He will try other companies with out disclosing the heart problem. I told him. He's screwed. 

[scubascuba3]

20 minutes ago, Larryst said:

Here's the whole story on what happened. The guy had insurance about 2 years. He bought the cheapest plan they had. He then had a motorbike accident last February. Everyone told him most insurance companies won't pay or hardly anything on motorbike accidents. He got mad because they wouldn't pay. I told him to upgrade his policy to a better plan. Instead he switched isurance company for a different plan. 4 months later he went to Bangkok Pattaya Hospital with heart problem. New insurance company told him preexisting condition. Now has to pay out of his own pocket. Knowing him. He will try other companies with out disclosing the heart problem. I told him. He's screwed. 

I would expect insurance companies to pay out on accidents as they haven't got a pre-existing condition get out.

 

A friend had Pacific Cross payout on a detached retina although only been with them a few months, an unnecessary delay though while they tried to find  a way out. Interestingly they denied a follow up cataracts op that was caused by the detached retina op

[The Fugitive]

24 minutes ago, Larryst said:

Here's the whole story on what happened. The guy had insurance about 2 years. He bought the cheapest plan they had. He then had a motorbike accident last February. Everyone told him most insurance companies won't pay or hardly anything on motorbike accidents. He got mad because they wouldn't pay. I told him to upgrade his policy to a better plan. Instead he switched isurance company for a different plan. 4 months later he went to Bangkok Pattaya Hospital with heart problem. New insurance company told him preexisting condition. Now has to pay out of his own pocket. Knowing him. He will try other companies with out disclosing the heart problem. I told him. He's screwed. 

Refusing claims on the basis of undiagnosed preexisting conditions worries me. Someone suffers a heart attack, the hospital then discovers their arteries are 'furred up' with plaque (arteriosclerois). Could they argue that this didn't occur overnight and must have existed at the time you took out your policy? I have read that arteriosclerois can begin in your 20's. Mild cases usually don't have any symptoms.

[scubascuba3]

4 minutes ago, The Fugitive said:

Refusing claims on the basis of undiagnosed preexisting conditions worries me. Someone suffers a heart attack, the hospital then discovers their arteries are 'furred up' with plaque (arteriosclerois). Could they argue that this didn't occur overnight and must have existed at the time you took out your policy? I have read that arteriosclerois can begin in your 20's. Mild cases usually don't have any symptoms.

Also high blood pressure, diabetes are reasons to deny claims for heart attack due to cardiovascular disease. Thing to do is email your insurer to get confirmation 

[Lorry]

5 hours ago, scubascuba3 said:

I would expect insurance companies to pay out on accidents as they haven't got a pre-existing condition get out.

You have no idea how creative insurance companies are.

Many Anglo-Saxon and Thai companies exclude motorcycle accidents, anyway. 

 

But this is a good one from an EU insurance (motorcycle accidents are covered):

(Former) heroin addict had an accident. Insurance said,  if she was under the influence of heroin at the time, according to our T&C she isn't covered,  because her addiction caused the accident. 

If she was not high on heroin at the time of the accident,  she must have been in withdrawal which would not be the case if she weren't an addict - so her addiction caused the accident, again. So, whatever,  we won't pay.

 

The girl was a low-class Thai,  married to a European labourer. What could possibly go wrong?

Turned out, the husband had a nice boss (small company), the boss had a lawyer, the lawyer knew the boss of the legal department of the insurance. 

Coverage required just a phone call. 

 

Lesson: if you have insurance you should have a lawyer,  too.

[Etaoin Shrdlu]

59 minutes ago, Lorry said:

You have no idea how creative insurance companies are.

Many Anglo-Saxon and Thai companies exclude motorcycle accidents, anyway. 

 

But this is a good one from an EU insurance (motorcycle accidents are covered):

(Former) heroin addict had an accident. Insurance said,  if she was under the influence of heroin at the time, according to our T&C she isn't covered,  because her addiction caused the accident. 

If she was not high on heroin at the time of the accident,  she must have been in withdrawal which would not be the case if she weren't an addict - so her addiction caused the accident, again. So, whatever,  we won't pay.

 

The girl was a low-class Thai,  married to a European labourer. What could possibly go wrong?

Turned out, the husband had a nice boss (small company), the boss had a lawyer, the lawyer knew the boss of the legal department of the insurance. 

Coverage required just a phone call. 

 

Lesson: if you have insurance you should have a lawyer,  too.

 

This proves that relationships can help solve issues such as this.

 

One relationship that is also very important is the one between your insurance broker and the insurance company. A broker with a large book of business with the insurer will have leverage that an individual insured does not have and can often resolve issues such as this. Your broker is your hired gun and you should use him or her in this type of situation. But choose a good broker and ask about their relationship with the insurance company. In general, avoid brokers that have ownership links to an insurance company, as that creates a conflict of interest.

 

One potential problem with going to a lawyer right off the bat is that the insurance company will usually then stop discussions or negotiations with the insured or the insured's broker and become completely intransigent. Your lawyer will be delighted as this keeps his meter running with all the back-and-forth correspondence. My suggestion would be to negotiate through your insurance broker first, approach the regulator second and only resort to the lawyer and courts if the first two fail and you are sure you're on solid ground legally.

[Lorry]

1 hour ago, Etaoin Shrdlu said:

. My suggestion would be to negotiate through your insurance broker first, approach the regulator second and only resort to the lawyer and courts if the first two fail and you are sure you're on solid ground legally.

Afaik this is the best procedure in Thailand. 

In the above case, the regulator would have been the regulator in Europe, which would have taken many months to react. 

The girl was in Bangkok Hospital and needed a payment guarantee fast.

Oh, and this insurance doesn't use brokers.  But what you say about brokers is true.

[Larryst]

I really think the guy I mentioned posted, made his own problems. Doesn't listen, doesn't take any responsiblity and for the heart problem. He did it himself. By over doseing steroids and testerone shots for years. He will pay in the long run.