I really hate sending out claim rejection notices to clients. Lately though, we have had to send out quite a few.
Looking through them to see why, I discovered that most of the claims had one thing in common: They were for follow up OPD care after release from an IPD stay in the hospital. Yet the insured's insurance plan allowed for OPD follow up care within so many days release from the hospital. And the claims were within this time limit.
"Oh, oh..." I thought, "Going to be reading about this on a few forums."
In spite of what many people would like to believe, the insurance company must follow the terms and conditions of the insurance policy. The insurance policy is a contract approved by the government for the protection of the insured and the insurer.
That said, I still must be able to explain the rejections to my clients. Actually, the reason for these rejections is quite simple, if you understand the difference between IPD and OPD, and you understand the fact that there are three distinctly different types of OPD coverage plans available in Thailand, depending on the level of health insurance coverage you purchase.
Hospital Inpatient care (IPD) requires that you have a medical problem that is serious enough for a doctor to admit you into the hospital for an overnight stay. (Some insurance companies allow you to be released after 6 hours; others require you to stay longer. In any case, the insurance company pays for a full overnight stay.)
While you are in the hospital the insurance company pays for your room & board & nursing care, as well as surgery costs and one doctor visit to you per day. Most importantly, though, they pay for "Hospital General Expenses" - which includes just about everything required for your medical treatment not included elsewhere.
This can quickly become the most costly part of your hospital bill. Outpatient Follow-up Care is normally covered under "Hospital General Expenses."
Hospital Outpatient care (OPD) is optional with most insurance policies. OPD allows you to walk into the hospital and visit with a doctor for any medical reason, no matter how minor. Because of this ease of use, OPD tends to be more costly for the benefit it provides. For this reason, and because of the low cost of doctor visits in Thailand, most insureds choose not to take this option.
Most health insurance plans sold in Thailand provide coverage in the mid to low range. The OPD coverage options range from 600 baht per doctor visit per day up to 3,000 baht per visit per day, for up to 30 days per year.
The higher coverage plans provide OPD coverage ranging from 25,000 baht per year to 75,000 baht per year. There are no limits on usage, but when the coverage is used up, there is no more outpatient coverage for the rest of the year.
One of the best OPD coverage "options" available in Thailand is actually totally integrated with the insurance plan it supports. It only becomes "optional" when you remove the OPD coverage and take a premium discount,
Why no post-hospitalization OPD follow up coverage?
The reason depends upon the level of health coverage you bought. With the mid to low coverage plans, if you used up the maximum figure shown in your policy schedule for "Hospital General Expenses", there will be no OPD follow-up coverage for you when you get released from the hospital.
This is in spite of the fact that you haven't used up the Major Medical support coverage. Major Medical supports IPD only, not OPD. Having OPD might have helped, depending on the amount. Spending the money for higher coverage, without OPD, might be better.
With some of the high-end plans, if you don't have OPD, then you won't have post-hospitalization OPD follow-up coverage.
If you put the money out to have the best medical coverage, don't short-change yourself by leaving off the OPD