How to reduce the risk of insurance claim denials?

[richard_smith237]

1 minute ago, Cardano said:

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

 

Are they ?... all exactly the same ???

 

I have just gone through the process of renewing... 

Some ask for 5 years history... (i.e. if you have had surgical treatment in the last 5 years).

Some ask for full history... (i.e. if you have ever had surgical treatment).

Some ask for parental history (heart and cancer) others do not.

 

Equally so, the insurance companies have different underwriting teams, some may be more accommodating than others. 

 

It is also known (or rather, its been commonly advised by Sheryl) that Thai companies have less oversight than International Insurance companies and thus any response which may seem unfair is handled differently.... (though international cover is more expensive).

 

So... I don't think they are the same at all - in fact I think its quite a minefield of differences and variables. 

[richard_smith237]

7 minutes ago, Yellowtail said:

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. 

 

I think thats a valid point....  BUT....  we still need cover. 

 

In my example... I had a snapped tendon, surgically repaired - exclusions now include the whole ankle, so if I have a motorcycle accident and get my ankle broken, it seems thats not covered. 

 

Its the use of every perceivable dash of 'wiggle room' that I object to.... 

 

--------

 

I still believe ALL long termers here (those on Non-Imm visas etc) should have full insurance here and it should be provided with the Visa (at a resonable cost) that allow for treatment of any kind pre-existing conditions or not.... (i.e. in much the same manner Thai's and overseas citizens can pay in to the UK National Health Service, we can pay into the Thai Health Care system and receive the same care as Thai's)...   

 

... If 'we' want better private treatment, that is also our choice and we can pay for 'extra private' care if we so wish. 

 

 

 

 

 

[Ralf001]

On 2/17/2025 at 6:32 AM, bkk6060 said:

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.

 

Bangkok hospital Pattaya most definitely shares patient history with Jomtien hospital

Both hospitals are part of the BDMS network.

 

 

[Yellowtail]

4 minutes ago, richard_smith237 said:

 

I think thats a valid point....  BUT....  we still need cover. 

 

In my example... I had a snapped tendon, surgically repaired - exclusions now include the whole ankle, so if I have a motorcycle accident and get my ankle broken, it seems thats not covered. 

 

Its the use of every perceivable dash of 'wiggle room' that I object to.... 

 

--------

 

I still believe ALL long termers here (those on Non-Imm visas etc) should have full insurance here and it should be provided with the Visa (at a resonable cost) that allow for treatment of any kind pre-existing conditions or not.... (i.e. in much the same manner Thai's and overseas citizens can pay in to the UK National Health Service, we can pay into the Thai Health Care system and receive the same care as Thai's)...   

 

... If 'we' want better private treatment, that is also our choice and we can pay for 'extra private' care if we so wish. 

 

 

What might a visa cost if included full medical coverage regardless of preexisting conditions? 

 

What kind of magnet would that be for people needing bypass surgery and whatnot? 

 

I think it would be nice if they offered insurance at or near cost to use in the government system, where you are assigned to the closest government hospital close to your home, and included an annual checkup. 

 

One big problem is that many people are used to medical coverage being "free" and are unwilling and or unprepared to pay anything. 

 

 

[richard_smith237]

2 minutes ago, Yellowtail said:

What might a visa cost if included full medical coverage regardless of preexisting conditions? 

 

What kind of magnet would that be for people needing bypass surgery and whatnot? 

 

Agreed... its a delicate 'game'...   But the 'long termers' are not here for medical treatment, though, it might attract those who are otherwise detracted due to their medical conditions. 

 

I think 'long termers' and 'tourists' could be treated differently from a medical insurance perspective - where tourists are required to show 'travel insurance'... and anyone with a visa has already paid into the national system and receives an insurance card.

 

 

2 minutes ago, Yellowtail said:

I think it would be nice if they offered insurance at or near cost to use in the government system, where you are assigned to the closest government hospital close to your home, and included an annual checkup. 

 

I believe this would be a workable solution - medically elective treatment to be held at the government hospital closest to your home - this would mean the 'elderly expats' have some cover.

Emergency treatment at 'any hospital' (as per law - for at least 72 hours) - this avoids hospitals kicking out people through no cover etc.

 

2 minutes ago, Yellowtail said:

One big problem is that many people are used to medical coverage being "free" and are unwilling and or unprepared to pay anything. 

 

As they should... I believe medical health care to be a basic human right. 

But, of course, it must be paid for - I don't see anything wrong in contributing to the national system ( a fair amount ) in much the same way, foreign nationals have to pay the NHS surcharge.

 

 

 

[Yellowtail]

9 minutes ago, richard_smith237 said:

 

Agreed... its a delicate 'game'...   But the 'long termers' are not here for medical treatment, though, it might attract those who are otherwise detracted due to their medical conditions. 

Might? 

9 minutes ago, richard_smith237 said:

I think 'long termers' and 'tourists' could be treated differently from a medical insurance perspective - where tourists are required to show 'travel insurance'... and anyone with a visa has already paid into the national system and receives an insurance card.

I don't think real tourists are not an issue. The government needs to come down hard on rental companies that do not mandate full coverage on vehicles they rent, and make the companies liable.

 

People that pay into the national system already get coverage. 

 

9 minutes ago, richard_smith237 said:

I believe this would be a workable solution - medically elective treatment to be held at the government hospital closest to your home - this would mean the 'elderly expats' have some cover.

Emergency treatment at 'any hospital' (as per law - for at least 72 hours) - this avoids hospitals kicking out people through no cover etc.

I agree

9 minutes ago, richard_smith237 said:

As they should... I believe medical health care to be a basic human right. 

But, of course, it must be paid for - I don't see anything wrong in contributing to the national system ( a fair amount ) in much the same way, foreign nationals have to pay the NHS surcharge.

 

I do not. I do not see medical care to be a basic human right any more than food and shelter are rights. 

 

[Cardano]

6 hours ago, richard_smith237 said:

 

Are they ?... all exactly the same ???

 

I have just gone through the process of renewing... 

Some ask for 5 years history... (i.e. if you have had surgical treatment in the last 5 years).

Some ask for full history... (i.e. if you have ever had surgical treatment).

Some ask for parental history (heart and cancer) others do not.

 

Equally so, the insurance companies have different underwriting teams, some may be more accommodating than others. 

 

It is also known (or rather, its been commonly advised by Sheryl) that Thai companies have less oversight than International Insurance companies and thus any response which may seem unfair is handled differently.... (though international cover is more expensive).

 

So... I don't think they are the same at all - in fact I think its quite a minefield of differences and variables. 

I didn't infer they were all exactly the same I said they all have the same standard T&C's. Primarily your contract is for 1 year and any condition arising in that year will be excluded in any future renewals.

[richard_smith237]

Just now, Cardano said:

I didn't infer they were all exactly the same I said they all have the same standard T&C's. Primarily your contract is for 1 year and any condition arising in that year will be excluded in any future renewals.

 

Will it ???...   It seems you suggest that if I have a heart attack this year.... and wish to renew with the same insurance provider next year, they will only continue with an exclusion.... 

 

... I'm not so sure this is true with 'continuing' the policy.... (its certainly not true of international health policies)... 

 

i.e. it means that someone who is diagnosed with cancer in their 10th month of cover, only can get 2 months of treatment before they can never be covered again....  

 

I just don't see this as plausible....   as I understood it, renewals are based on the 'original' contract and conditions of first application and that only exclusions based 'age limits' can be brought in at upper levels depending on insurer.

[Cardano]

2 minutes ago, richard_smith237 said:

 

Will it ???...   It seems you suggest that if I have a heart attack this year.... and wish to renew with the same insurance provider next year, they will only continue with an exclusion.... 

 

... I'm not so sure this is true with 'continuing' the policy.... (its certainly not true of international health policies)... 

 

i.e. it means that someone who is diagnosed with cancer in their 10th month of cover, only can get 2 months of treatment before they can never be covered again....  

 

I just don't see this as plausible....   as I understood it, renewals are based on the 'original' contract and conditions of first application and that only exclusions based 'age limits' can be brought in at upper levels depending on insurer.

The original contract will state pre-existing conditions are excluded, at renewal of said contract any pre-existing condition is excluded. So yes if you had a heart attack or was diagnosed with cancer prior to renewal those conditions will be excluded from cover at the renewal.

[jeffandgop]

10 hours ago, Cardano said:

I didn't infer they were all exactly the same I said they all have the same standard T&C's. Primarily your contract is for 1 year and any condition arising in that year will be excluded in any future renewals.

That is simply not true.  I have had health insurance with a Thai company for at least the last 10 years.  The first year's policy limited the term of pre-condition exclusion so today I am covered for all noted pre-conditions I disclosed at the beginning policy AND no renewal has ever excluded conditions related to any treatment received in the year prior to renewal.

[gargamon]

49 minutes ago, jeffandgop said:

That is simply not true.  I have had health insurance with a Thai company for at least the last 10 years.  The first year's policy limited the term of pre-condition exclusion so today I am covered for all noted pre-conditions I disclosed at the beginning policy AND no renewal has ever excluded conditions related to any treatment received in the year prior to renewal.

And what Thai insurance company is that?

[jeffandgop]

4 hours ago, gargamon said:

And what Thai insurance company is that?

You can msg me if u want to know; don't want any fallout by publicizing the name.

But I do need to clarify my earlier statement.

My insurance policy states that pre-existing conditions are not covered during the first year of the policy unless the covered person has declared the pre-existing condition at the time of application AND the insurance company agrees to cover said pre-existing condition.  Or, all pre-existing conditions not known at the time of the application are/willbe covered if having had continual policy coverage by the company for 3 successive years, and has had no symptoms or sought medical advice for a period of 5 years for a suspect condition before the inception of the first policy year.  

Apologize for my brevity of my first response; it was not totally correct.

But still, never has my insurance company taken a position that something that they had covered was now a pre-condition at the time of the policy renewal.

[richard_smith237]

14 hours ago, Cardano said:

The original contract will state pre-existing conditions are excluded, at renewal of said contract any pre-existing condition is excluded. So yes if you had a heart attack or was diagnosed with cancer prior to renewal those conditions will be excluded from cover at the renewal.

 

To be clear...  I'd like to be sure you understand what the word 'renewal' means.

- Renewal is not the initial application - its the renewal of a pre-existing contract.

- Your comments seem to refer to 'primary or initial application'.

 

This, you've responded to my question with a response that has not accommodated the question correctly.

 

15 hours ago, Cardano said:

Primarily your contract is for 1 year and any condition arising in that year will be excluded in any future renewals.

 

This is not true (as far as I am aware)... Any 'pre-existing' conditions known before the initial application will likely be excluded - but the cannot be excluded from renewal of existing coverage. 

 

BUT, IF something were to happen in that first year of coverage (i.e. I used the example of a heart attack) it does not mean that the Insurance Provider will excluded that from continued membership the following year (i.e continuing yearly renewals) as they are already locked into the original statement.

 

14 hours ago, Cardano said:

The original contract will state pre-existing conditions are excluded, at renewal of said contract any pre-existing condition is excluded. So yes if you had a heart attack or was diagnosed with cancer prior to renewal those conditions will be excluded from cover at the renewal.

 

You've muddied the waters between 'original application' and renewal of existing cover. 

 

Example: I used. IF took out cover with no pre-existing conditions and in that year of cover I had a heart attack, any renewal of cover will not exclude heart conditions - renewal is not a reapplication, its simply paying for another year of the existing cover under the original conditions and agreements. 

 

 

 

 

[Cardano]

6 hours ago, jeffandgop said:

That is simply not true.  I have had health insurance with a Thai company for at least the last 10 years.  The first year's policy limited the term of pre-condition exclusion so today I am covered for all noted pre-conditions I disclosed at the beginning policy AND no renewal has ever excluded conditions related to any treatment received in the year prior to renewal.

Well done you if that's the case, and if true is a very rare exception rather than the rule. Which company is this so your claim can be verified against their T&C's? 

[Tom100]

On 2/17/2025 at 3:02 PM, 1FinickyOne said:

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... 

Agreed. In the US, the average claim denial rate is currently 16% See below. 

 

Luigi Mangione (who shot the health insurance CEO) wrote the words "delay," "deny," and "depose" on the bullets used in a crime, with each word appearing on a separate bullet casing; this phrase is often used to criticize tactics employed by insurance companies like delaying payments and denying claims. 

 

I had Thai insurance with Pacific Cross for 2 years.  I only tried to make one claim but they made the process extremely time-consuming, ignored/misplaced the docs I mailed in, refused to accept claim forms in PDF format - mail only, then claimed delay was my fault, then told me that my insurance would go up more than the claim amount. So they promised to punish me for a legitimate claim. I dropped the claim, next year (2025) they increased my annual premium over 40% despite no claims ever. What fraudsters...using the common industry tactics of delay, deny, and depose.

[VBF]

1 hour ago, richard_smith237 said:

 

To be clear...  I'd like to be sure you understand what the word 'renewal' means.

- Renewal is not the initial application - its the renewal of a pre-existing contract.

- Your comments seem to refer to 'primary or initial application'.

 

This, you've responded to my question with a response that has not accommodated the question correctly.

 

 

This is not true (as far as I am aware)... Any 'pre-existing' conditions known before the initial application will likely be excluded - but the cannot be excluded from renewal of existing coverage. 

 

BUT, IF something were to happen in that first year of coverage (i.e. I used the example of a heart attack) it does not mean that the Insurance Provider will excluded that from continued membership the following year (i.e continuing yearly renewals) as they are already locked into the original statement.

 

 

You've muddied the waters between 'original application' and renewal of existing cover. 

 

Example: I used. IF took out cover with no pre-existing conditions and in that year of cover I had a heart attack, any renewal of cover will not exclude heart conditions - renewal is not a reapplication, its simply paying for another year of the existing cover under the original conditions and agreements. 

I disagree. I have to notify my insurers about preexisting conditions and then pay an extra premium for an extension that is actually extra cover for said conditions.

 

Whilst the basic policy rolls over annually, this extension is clearly stated as being for 1 year only so I shall need to renew it again next year.

[richard_smith237]

49 minutes ago, Tom100 said:

Agreed. In the US, the average claim denial rate is currently 16% See below. 

 

Luigi Mangione (who shot the health insurance CEO) wrote the words "delay," "deny," and "depose" on the bullets used in a crime, with each word appearing on a separate bullet casing; this phrase is often used to criticize tactics employed by insurance companies like delaying payments and denying claims. 

 

I had Thai insurance with Pacific Cross for 2 years.  I only tried to make one claim but they made the process extremely time-consuming, ignored/misplaced the docs I mailed in, refused to accept claim forms in PDF format - mail only, then claimed delay was my fault, then told me that my insurance would go up more than the claim amount. So they promised to punish me for a legitimate claim. I dropped the claim, next year (2025) they increased my annual premium over 40% despite no claims ever. What fraudsters...using the common industry tactics of delay, deny, and depose.

 

Thank you...  And it was for stories such as this that I avoided Pacific Cross even though their premiums were better, their coverage appeared decent... 

 

... I knew from enough mentions on this forum that they were a company I could not truly rely upon.

 

 

Thus: I thank all those for their honesty when discussion their claims and experiences on forums such as this. 

[richard_smith237]

16 minutes ago, VBF said:

I disagree. I have to notify my insurers about preexisting conditions and then pay an extra premium for an extension that is actually extra cover for said conditions.

 

Whilst the basic policy rolls over annually, this extension is clearly stated as being for 1 year only so I shall need to renew it again next year.

 

I think you've misunderstood the concept of 'renewing an existing policy'....  (either that, or I have)... 

 

I agree about listing pre-existing conditions....  but not your other comment.

 

IF something happens while covered (i.e. I have heart attack)... i.e. after taking the insurance, it cannot then be counted as an exclusion in the the following years cover (i.e. after next years renewal).

 

 

 

 

 

 

[VBF]

48 minutes ago, richard_smith237 said:

 

I think you've misunderstood the concept of 'renewing an existing policy'....  (either that, or I have)... 

 

I agree about listing pre-existing conditions....  but not your other comment.

 

IF something happens while covered (i.e. I have heart attack)... i.e. after taking the insurance, it cannot then be counted as an exclusion in the the following years cover (i.e. after next years renewal).

 

Sorry but you're incorrect.

The basic policy continues but the covered preexisting conditions are ONLY covered under the extension I mentioned earlier.

Mine is for a previous heart attack so without the extension, any future heart problems are not covered.

This extension is valid for a year at a time.

Does that clarify @richard_smith237 ?

[jeffandgop]

2 hours ago, Cardano said:

Well done you if that's the case, and if true is a very rare exception rather than the rule. Which company is this so your claim can be verified against their T&C's? 

Read my clarifications I added 3 hours ago for better information 

[richard_smith237]

38 minutes ago, VBF said:

Sorry but you're incorrect.

The basic policy continues but the covered preexisting conditions are ONLY covered under the extension I mentioned earlier.

Mine is for a previous heart attack so without the extension, any future heart problems are not covered.

This extension is valid for a year at a time.

Does that clarify @richard_smith237 ?

Not really, not at all….

 

Because it is my understanding that ‘if’s have a hip issue this year while covered, and continuing (rolling over) the same cover to next year, I’ll still be covered for further ‘hip issues’…. (Hip issues wouldn’t suddenly become an exclusion).

 

Perhaps we need an expert on this @Sheryl to clarity…. 

 

 

[VBF]

1 hour ago, richard_smith237 said:

Not really, not at all….

 

Because it is my understanding that ‘if’s have a hip issue this year while covered, and continuing (rolling over) the same cover to next year, I’ll still be covered for further ‘hip issues’…. (Hip issues wouldn’t suddenly become an exclusion).

 

Perhaps we need an expert on this @Sheryl to clarity…. 

 

I don't....just looked at my trip extension document and THAT PART is clearly stated as an ANNUAL CONTRACT 

So each year I must renew that part of the policy to cover myself against heart attacks and related ailments. Any new issues are covered as the year rolls on but they may then become existing issues at renewal.

 

Respectfully, whatever anyone else thinks the wording of my policy is what counts.

 

Your understanding may well be true for YOUR policy, I'm certain about mine.

Cheers!

[Sheryl]

4 hours ago, richard_smith237 said:

Not really, not at all….

 

Because it is my understanding that ‘if’s have a hip issue this year while covered, and continuing (rolling over) the same cover to next year, I’ll still be covered for further ‘hip issues’…. (Hip issues wouldn’t suddenly become an exclusion).

 

Perhaps we need an expert on this @Sheryl to clarity…. 

 

 

Pre-existing conditions mean conditions that existed prior to  the start of the policy.

 

With normal health insurance annual premium payments are not a "renewal" . Just a premium . Same contract remains in effect.

 

I note @VBFmentioned a "trip extension" so he may have  a travel policy which is a different thing. 

 

 

[VBF]

2 hours ago, Sheryl said:

Pre-existing conditions mean conditions that existed prior to  the start of the policy.

 

With normal health insurance annual premium payments are not a "renewal" . Just a premium . Same contract remains in effect.

 

I note @VBFmentioned a "trip extension" so he may have  a travel policy which is a different thing. 

 

 

Thanks Sheryl.... that's exactly the case👍👍

Mine is travel insurance which I thought I mentioned but maybe not. 

[richard_smith237]

10 minutes ago, VBF said:

Thanks Sheryl.... that's exactly the case👍👍

Mine is travel insurance which I thought I mentioned but maybe not. 

 

Seems we've been talking 'cross purposes'...  

 

I've been referring to health insurance....  which automatically rolls over (renews) upon payment.

You've been referring to travel insurance, which is something quite different. 

 

 

With Health insurance - we can have elective treatment here and the contract rolls over.

But, with your Travel insurance, any 'elective treatment' will need to be carried out in your home country... it basically covers you for emergency cases. 

 

[VBF]

17 minutes ago, richard_smith237 said:

 

Seems we've been talking 'cross purposes'...  

 

I've been referring to health insurance....  which automatically rolls over (renews) upon payment.

You've been referring to travel insurance, which is something quite different. 

 

 

With Health insurance - we can have elective treatment here and the contract rolls over.

But, with your Travel insurance, any 'elective treatment' will need to be carried out in your home country... it basically covers you for emergency cases. 

 

Exactly so! We got there at last.

Ain't communication grand 😆

[richard_smith237]

1 minute ago, VBF said:

Exactly so! We got there at last.

Ain't communication grand 😆

 

What you mean 'communication isn't big' ???   

 

Indeed... we got there in the end...  'a beer raised to your good health and not needing any of that insurance cover you have'... 

 

 

 

 

[VBF]

1 minute ago, richard_smith237 said:

 

What you mean 'communication isn't big' ???   

 

Indeed... we got there in the end...  'a beer raised to your good health and not needing any of that insurance cover you have'... 

Back at ya..... Cheers 🍻🍻

[Tom100]

23 hours ago, richard_smith237 said:

 

Thank you...  And it was for stories such as this that I avoided Pacific Cross even though their premiums were better, their coverage appeared decent... 

 

... I knew from enough mentions on this forum that they were a company I could not truly rely upon.

 

 

Thus: I thank all those for their honesty when discussion their claims and experiences on forums such as this. 

Before I bought Pacific Cross insurance, they said they would pay hospital claims directly online if I preregistered with hospitals.

After I went to a hospital and had a valid claim that was submitted by the hospital online it was automatically DENIED.

Pacific Cross told me they did not know who I was. I said I was the person that bought the policy. They required that I prove my identity with THREE COLOR COPIES OF MY PASSPORT. MUST BE MAILED TO COMPANY. NO EMAILS ALLOWED. They misplaced the mail and asked for the tracking number, then said I was at fault. 

THE PERSON THAT SELLS INSURANCE FOR A COMMISSION IGNORES YOU AFTER YOU PAY.

DO NOT TRUST PACIFIC CROSS. 

 

Many insurance companies use delaying tactics to avoid paying claims. This is how they manage profitability. They only certainty is self-insurance. 

 

If you get cancer, you may be covered for the first year, but your policy the following year could be 5-10 million baht! Your policy price will be increased to recoup your claims and more. 

 

 

 

[global expat]

@Tom100 

 

I realize emergency fund is a backup in case they deny it.