How to reduce the risk of insurance claim denials?

[global expat]

Other than using a reputable broker, what other strategies can individuals use to minimize the risk of claim denials and ensure their insurance will pay out when needed? I'm worried my current and future insurance providers might not come through in a critical situation.

[Hummin]

20 minutes ago, global expat said:

Other than using a reputable broker, what other strategies can individuals use to minimize the risk of claim denials and ensure their insurance will pay out when needed? I'm worried my current and future insurance providers might not come through in a critical situation.

Be honest about your history and prehistoric health issues, and pay what it cost to get the best option. 

[Sheryl]

2 hours ago, Hummin said:

Be honest about your history and prehistoric health issues, and pay what it cost to get the best option. 

And make sure you understand the policy terms and follow the corrrect procedures if hospitalized (usually this means obtaining pre-authorization).

 

Moved  to Insurance forum. 

[OneMoreFarang]

10 minutes ago, Sheryl said:

And make sure you understand the policy terms and follow the corrrect procedures if hospitalized (usually this means obtaining pre-authorization).

 

I think that can't be said loud enough. Look at the details of your contract. Don't assume this and that.

Too many people don't know what they sign and then later they are surprised that they don't get what they hoped for.

Read it! 

[BritManToo]

3 hours ago, global expat said:

what other strategies can individuals use to minimize the risk of claim denials

My strategy is not to have insurance (beyond government requirement).

[global expat]

Thanks guys 

[hereforgood]

On 2/15/2025 at 12:37 PM, global expat said:

Other than using a reputable broker, what other strategies can individuals use to minimize the risk of claim denials and ensure their insurance will pay out when needed? I'm worried my current and future insurance providers might not come through in a critical situation.

I don't have private medical insurance I have Thailand government insurance since I worked here for many years that covers everything and it works okay for me no hassles at all. 

I used to have a very good customer when I was working that was an insurance agent a foreigner. He told me and these are his words mind you coming from a guy that sells insurance. He said the minute a claim comes in the first thing the insurance company does is go into defense mode they have people that look at ways that they can avoid paying out the claim or paying less than the claim is for. He said that's just the way it is with insurance companies. Over the years dealing with them in the US I have no doubt he's totally correct. 

 

I'm sure some will say here they've had no problems and everything is went smooth because they're not all the same. But this information came to me directly from a guy who sells the product take it for what it's worth

[jerrymahoney]

To the above, seems to me that is the nature of the beast. Health insurers do little if any corroboration of the medical statements presented by a potential policy holder upon application.

They will only start any real investigation when presented with a claim. If no claim has been presented, then, to them, what is the difference?

[bkk6060]

I was told by an agent the insurance companies do check with hospitals after a claim was made to see if prior treatment was given.  Interesting,  Bangkok Hospital staff told me their hospitals records are not connected and they do not have access to other Bangkok Hospitals records.  So, if true and you were treated in Pattaya, but later went to BH in Hua Hin they would not have a record of the Pattaya treatment.

This being said, yes best to be honest on the application to avoid issues.

[IsaanT]

5 hours ago, bkk6060 said:

Bangkok Hospital staff told me their hospitals records are not connected and they do not have access to other Bangkok Hospitals records.  So, if true and you were treated in Pattaya, but later went to BH in Hua Hin they would not have a record of the Pattaya treatment.

 

We live in an increasingly-connected world (as all the members discussing Thai taxation are learning about global taxation).  I wouldn't assume hospital records will remain unconnected.

Having said that, TiT so it may or may not happen as quickly as you might imagine.

[1FinickyOne]

I have no faith in insurance companies to pay out at all. Many years ago I watched some sort of expose and one of the former workers said that her job was to deny any, and every  first time claims - and to persist in this way... 

 

I know for myself, if I am not well, the last hting I will want to do is fight about anything, including and especially money. 

 

I am sure that other companies are more honorable... I guess check references as thoroughly as you can. 

[global expat]

@hereforgood @1FinickyOne it seems a combination of an emergency fund or reasonably priced  public hospital are a back up in case they deny a claim.  Bases on those negative trustpilot reviews, even the good ones like cigna try to deny claims. 

 

 

[1FinickyOne]

58 minutes ago, global expat said:

@hereforgood @1FinickyOne it seems a combination of an emergency fund or reasonably priced  public hospital are a back up in case they deny a claim.  Bases on those negative trustpilot reviews, even the good ones like cigna try to deny claims. 

 

 

I will say this - I would not want to be in the business of paying medical bills for someone else, especially older people who are sure going to need your services at some point... I'd be trying to close down the local ice cream shop by any means possible.. 

[richard_smith237]

I had a small kidney stone a number of years ago... Found on a routine medical checkup and that info was placed in my medical notes.

 

Approximately 5 years later, I had another medical check-up, and no kidney stone was found. 

Information was placed in my notes that 'a previously observed small kidney stone was no longer present'....  (i.e. the absence of a kidney stone was noted).

 

Fast forward about 4.5 years and I had Kidney pain...    insurance pre-approved a proceedure (to have it blasted - lithotripsy)...   so I had the procedure at Bumrungrad (cost 130,000 baht).

 

Insurance, later refused to pay under the clause that 'Renal issues' were noted in my medical notes within the last 5 years (there was a 5 year cut off)... I argued that the comment in my notes was refering to the absense of a stone, rather than the presence, thus the medical check up was a confirmation of the 'absense of renal issues' rather than the presence of a pre-existing condition I should have notified them of (again - the moratorium on this was 5 years). 

 

I ended up paying out of pocket....  I've since been told that I had a case to 'contest' this with the Insurer (April Thailand), however, I travel a lot and did not want to run the risk of a powerful hospitial such as Bumrungrad placing a block on my passport because I owed them money (I'm not sure if they could do this, but due to my work I was not prepared to take any risk with hassles or delayed travel).

 

 

Short answer: Insurance companies will use 'any' amount of wiggle room, no matter how slim to work their way out of paying.

 

 

 

 

[richard_smith237]

Another point I want to make separately. 

 

I've recently need to secure my 'own' insurance over again (rather than a good cover through work). 

Over the past 3 years I've had a couple of Knee Ops - menicus repair, and ankle tendon repair... all injuries encountered through sports injuries. 

 

Its taken 6 weeks of back and forth with insurance companies who agree full cover, then after time wasted inform me their underwriter will not cover anything to do with my knees or ankle.

 

... So it seems if I'm in a car accident and manage to damage my knee, they will not cover the injury - or they refuse to get nailed down to such specifics and just apply general exclusions.

 

If I have a motorcycle accident and twist my ankle, I don't think its covered... 

 

BUT... the language used is 'exclusion for Knee and right ankle diseases' - which seems specific - but really, gives them wiggle room.... 

 

I just have to hope nothing happens. 

 

-------------

 

Next renewal... I'll just use a completely new insurance company and lie....  then use a completely different hospital and check they are not using the same underwrites as my previous hospitals. 

 

Is that 'cheating the system' ???... maybe.... but, if a car hits me and damages my knees, is not because 3 years ago I had a meniscus repair !!!...   and don't believe if fair that insurance uses this to 'wiggle out'.... 

But... in the same context, if I have knee pain after running regularly, then its my own fault as I know have had meniscus damage...  so it would be fair for insurance to reject any such claim. 

 

The issue of course as mentioned is they take the 'slightest of comments' in any medical notes and use that to avoid any cover, which IMO is unfair....  Change insurers ??...  after being honest with many, I will have to do that, but I'll need more time to do better research to find companies that are not over lapping or information sharing... 

 

 

[richard_smith237]

6 hours ago, IsaanT said:

 

We live in an increasingly-connected world (as all the members discussing Thai taxation are learning about global taxation).  I wouldn't assume hospital records will remain unconnected.

Having said that, TiT so it may or may not happen as quickly as you might imagine.

 

 

I had a minor Arthorscopic knee surgery 6 months ago...   (trimmed back part of a damaged meniscus)...  15 mins was all it took....  stayed over night, no pain meds needed the next day etc... 

Felt perfect again...  But now its a pre-existing condition... 

 

Upon discharge there was a form that asked for approval to 'share information' - I refused to sign it. 

I was told I had to sign it.... I refused to sign it....  I told them information privacy is important to me and they are not to share this information with any other service provider. 

 

Realistically - I don't think they will care - its just paperwork and if an insurer wants my medical notes I don't think the hospital staff will be looking for the 'signature' that allows sharing of medical information, thats too much work... they'll just 'do what they always do' and conform and share the information. 

 

 

[Cardano]

What many don't realise is that medical/health insurance is a 1 year contract and that any ailment occuring during that period is classed as a pre-existing condition for any future cover, irrespective of the insuarnce company. 
In November 2022 a work collegue was experiencing chest pains and admitted to a major private hospital in BKK he was subsequently diagnosed with severe coronary issues and underwent a triple bypass operation and prescribed drugs for the rest of his life. He was discharged middle of December with all costs paid by his insurance company until his contract expired at the end of December. He renewed his annual medical insurance at the beginning of January and a week later went in to septic shock, rushed back in to hospital where they determined his wounds were infected so they pumped him full of antibiotics and opened his wound scars to enable antiseptic cleaning each day he spent 6 weeks in ICU. The bill for his was treatment B1.3M, his insurance company advised him he was not covered as treatment required was due to a pre-existing condition and that all costs for his daily medications were also not covered from the end of December. Luckily after a lot of arguing the hospital admitted 75% culpability for the infection and reduced his bill accordingly. However he has to self fund all his related medication costs for the rest of his life.

[global expat]

@Cardano i am sorry for your colleague.

 

what is the name of the insurance company so we can avoid it?

 

You cannot trust private insurance. I realize we need an emergency fund in case they like to avoid paying us. 

 

 

 

 

[scottiejohn]

19 minutes ago, global expat said:

what is the name of the insurance company so we can avoid it?

Given the defamation laws in Thailand I would suggest that you DO NOT post the name!

[richard_smith237]

On 2/15/2025 at 3:08 PM, Sheryl said:

And make sure you understand the policy terms and follow the corrrect procedures if hospitalized (usually this means obtaining pre-authorization).

 

Moved  to Insurance forum. 

Pre-Authorisation is often a right proper annoyance....  especially for something serious (but not life threatening in which case its obvious treatment can be sought right away).

 

My previous insurance (Cigna Int'l) though my company (full cover, no exclusions etc)....   I wouldn't bother with pre-authorisation.

- After injuries (plural / though sports) I'd visit the hospital...  the operations were obviously needed anyway, so with or without approval I'd need the treatment (operation) regardless... 

 

.... And... sometimes the 'pre-authorisation' can take day days of waiting which I was not willing to go through (in pain).

... Dr's were excellent and I just get the Op booked immediately (often the following day), pay up, and then make the full claim....  (paid back into my account in less than a couple of weeks)....

 

Much better than waiting for the Pre-authorisation hassle then having them delay, missing an Op booking time because the underwriter is slow 'authorising' the treatment etc.

 

(and... even with Pre-authorisation, for a much earlier issue a while back now insurer (named after 4th month) Thailand still ended up refusing to pay after digging something out of some doctors notes from a past medical check up).

 

 

[richard_smith237]

18 minutes ago, scottiejohn said:

38 minutes ago, global expat said:

what is the name of the insurance company so we can avoid it?

Given the defamation laws in Thailand I would suggest that you DO NOT post the name!

 

In the interests of improving things for the forum community - Name the company.... 

 

This is not about defamation, its about who provides the best experience and who has had a negative encounter.....   this is important information for us all.

 

Its one of the reasons I have not chosen Pacific Cross as my health Insurance provider - based on comments here, where it has been repeatedly shown that they are more likely to dig for some reason and shoehorn out wiggle room not to pay out.... 

 

 

 

 

 

[Yellowtail]

I like insurance companies, and they have always been fair with me. 

 

That said, insurance companies are in the business of colleting premiums, not paying out claims. 

 

As others have said, if you have a preexisting condition, or medical history, be honest and up front about it. 

 

Understand your coverage. 

 

Do not file claims on things that are not covered

 

If your claim is denied, and you can make an argument why you think it should be approved, write a letter saying as much and resubmit. No need to get nasty, and this will often do the trick. 

[Yellowtail]

5 minutes ago, richard_smith237 said:

Pre-Authorisation is often a right proper annoyance....  especially for something serious (but not life threatening in which case its obvious treatment can be sought right away).

 

My previous insurance (Cigna Int'l) though my company (full cover, no exclusions etc)....   I wouldn't bother with pre-authorisation.

- After injuries (plural / though sports) I'd visit the hospital...  the operations were obviously needed anyway, so with or without approval I'd need the treatment (operation) regardless... 

 

.... And... sometimes the 'pre-authorisation' can take day days of waiting which I was not willing to go through (in pain).

... Dr's were excellent and I just get the Op booked immediately (often the following day), pay up, and then make the full claim....  (paid back into my account in less than a couple of weeks)....

 

Much better than waiting for the Pre-authorisation hassle then having them delay, missing an Op booking time because the underwriter is slow 'authorising' the treatment etc.

 

(and... even with Pre-authorisation, for a much earlier issue a while back now April Thailand still ended up refusing to pay after digging something out of some doctors notes from a past medical check up).

 

 

I had Cigna for years and Blue Cross Blue Sheild for a few years. After the first time, I never tried to get preapproval and never tried to get coverage at the provider. Pay the hospital, submit the bill and wait for reimbursement. 

[CharlieH]

Please do not "name & shame" on the forum, if you wish to share details in PM thats a choice.

[richard_smith237]

13 minutes ago, Yellowtail said:

I had Cigna for years and Blue Cross Blue Sheild for a few years. After the first time, I never tried to get preapproval and never tried to get coverage at the provider. Pay the hospital, submit the bill and wait for reimbursement. 

 

When the bill of an Op is north of half a mil (baht) thats some nice points on the card !!!... (towards flights etc).... 

Just so long as we can be confident the insurer will pay out (like Cigna)....

 

But... an earlier encounter (with a company named after the 4th month) means that can be hit and miss... with pre-authorisation, I took treatment at Bumrungrad, then after their refusal to pay, I started recieving warning letters from Bumrungrad had to pay out myself....   I would have otherwise opted a cheaper hospital for the treatment if being forced to pay out of pocket... 

... so I was 'doubly shafted' - first by getting pre-approval at a top hospital (for relatively simple treatment), then finding out its going to cost me a lot out of pocket when I'm sure I could have received treatment at half the price at a lesser known hospital with uglier nurses !!!

 

 

 

 

[Stargeezr]

I got covered by SMIG for medical insurance. I had to  make a claim

as I had a heart attack. It took 2 months and lots of paper work to get my

claim settled, with lots of paper work from my home country Canada, and my

family doctor. Thankfully I was not denied and now that I am back in Canada,

I have to be prepared to pay more for coverange in the future.

[Cardano]

@global expat

[Cardano]

@global expat
The name of the insurance company is irrelevant but it was a major international company, All apply the same conditions of cover and all are a single 12 month contract.

[Cardano]

15 hours ago, richard_smith237 said:

 

In the interests of improving things for the forum community - Name the company.... 

 

This is not about defamation, its about who provides the best experience and who has had a negative encounter.....   this is important information for us all.

 

Its one of the reasons I have not chosen Pacific Cross as my health Insurance provider - based on comments here, where it has been repeatedly shown that they are more likely to dig for some reason and shoehorn out wiggle room not to pay out.... 

 

 

 

 

 

The name is irrelvant. All apply the same industry standard T&Cs.

[Yellowtail]

5 hours ago, Stargeezr said:

I got covered by SMIG for medical insurance. I had to  make a claim

as I had a heart attack. It took 2 months and lots of paper work to get my

claim settled, with lots of paper work from my home country Canada, and my

family doctor. Thankfully I was not denied and now that I am back in Canada,

I have to be prepared to pay more for coverange in the future.

In all fairness to insurance companies, there is no shortage of people trying to cheat them. 

 

Imagine how much insurance would cost it they just paid everything that was submitted to them.