Insurance Problems

[kdf]

Hello gang,

I could use some advise.

I have health insurance with a company with a very good reputation and they have paid some small outpatient claims quickly and easily. I had an inpatient claim of slightly over 100,000. They refused to pay the hospital directly which feature figures prominently in their advertising. I then got a call from a pleasant physician a week or so after I was out. They had some concerns regarding my claim and we disused them. He said well we will be covering this claim. After about 5-7 minutes he called back, perhaps a bit embarrassed, and said that they had pre-existing condition questions and would only pay half in good faith. I subsequently got a letter from the general manager asking for more paperwork, without mentioning the good faith 50%.

I would assume that the medical consultant would be the deciding voice on medical issues and now I can not reach him. It is easy to jump to negative conclusions, but this company has treated me well in smaller issues for some time.

Any ideas?

kdf

[canopus1969]

Ask your Broker to sort it out with the Insurance company as they will have all the phone numbers

[scorecard]

Ask your Broker to sort it out with the Insurance company as they will have all the phone numbers

Agree, put the broker under pressure.

If the broker says 'There's nothing i can do", then get tough with the broker and (politely) demand action.

[kdf]

The broker has not been helpful.

She seems afraid of the big guns at the insurance office. BTW, this is NOT normal behavior for her as she is normally, pleasant, knowledgeable, and assertive.

Where else can one turn?

kdf

[jazzbo]

My only first-hand experience is with BUPA. Unless a total emergency, any such surgery would have to be approved in advance. Was your surgery approved in advance? Is your insurer now saying that you have (had) some pre-existing condition that you did not disclose on your application?

[rolfefox]

Ask your Broker to sort it out with the Insurance company as they will have all the phone numbers

I had an expensive operation at BKK Pattaya Hospital. I was told by BUPA that they found a 2 year old blood test that made my

case a pre-existing condition and would not pay...I appealed and presented information that this test was not relevant. It took time while they reviewed my case but they changed to my favor and paid. So my exprience is that they are fair when concidering pre-existing conditions.

[kdf]

No my insurance is not Bupa. It is a well respected brand and more expensive than Bupa. They do not require pre-auth for surgery, but would prefer it. As long as you go to one of their approved hospitals, the surgery is medically necessary, and not a pre-existing condition they should pay. The "fact" that they pay the hospital directly instead of reimbursing you, figures prominently in there pre-purchase presentation.

One of their reviewing Docs told me that he did not trust check ups done by Thai docs so my evidence of non-pre-existing status he will most likely deny. I am not sure what nationality of docs he expected me to find here in Thailand.

Any More ideas?

kdf

[kdf]

Interesting note on my health insurance. They paid for a late night ambulance trip, ER visit, and next day doc visit and meds. However still no clarity on inpatient surgery at well over 100,000 baht.

They have asked for more information, some does not exist, but they now say that they have not denied the claim, but this group promotes itself on the basis of paying approved hospitals directly and not going the reimbursement route.

Hope springs eternal.

kdf

[thaiericsweden]

The insurance company didn't pay the claim directly to the hospital for a simple reason.

The claims department was not sure if this was related to a pre-existing condition.

If you have only had your health insurance policy less than 2 years, this can be a problem.

In addition to the possibility of being related to a pre-existing condition, the doctors report may say something that gives rise to suspicion of this claim.

If you have had this insurance for over 2 years, there should be no problem concerning pre-existing conditions.

The insurance company is using delaying tactics to frustrate you.

If you don't get answers and the claim is not settled within a reasonable time frame, you have to register a complaint at the Office of Insurance Commission.

Go to the nearest Office of Insurance Commission and register a complaint against this Insurance company.

The OOIC helps all customers that have problems with insurance companies and speeds up the settlement.

I have assisted many times as a translator at the local OOIC office and I have seen first-hand that they really help customers that are being badly treated by insurance companies.

Here is the web address

http://www.oic.or.th

Sorry but it is only in Thai, ask a friend to help you read it.

Click in the blue column on the left of the page, second from the bottom is a listing of provincial OOIC offices.