Tell it to the OIC

There's a new sheriff in town

Being a stranger in a strange land causes many expats to become a bit paranoid at times. This can be especially true when considering the purchase of health and accident insurance in Thailand. Whom can you trust? What are the "hidden" exclusions that health insurers can use to get out of paying your claim?

Relax. The good news is that there is now "a new sheriff in town" (No, not Yingluk) here to protect buyers of insurance and make sure that they receive fair treatment from the insurance companies.

This new sheriff is called the "Office of Insurance Commission" (OIC). They recently replaced the former overseer of insurance, the "Department of Insurance" (DI), when it was discovered that they just weren't doing their job properly in terms of protecting insurance buyers. The OIC took over with a firm commitment to keep a tight rein on the insurance companies and to make certain that they maintained enough funds to pay their claims. Just this year, two auto insurers experienced the wrath of the OIC and were closed down. Unlike in the past, though, the insureds did not lose their coverage. They were given the choice of a large number of respected auto insurers to continue their coverage through until renewal time.

Like other types of insurance, health insurance Policy Terms and Conditions have to be approved by the OIC (and the DI before them). Therefore, most health insurance Policy Terms and Conditions are pretty much the same. It is the Policy Schedule (showing the coverage) and any Endorsements, which sets one policy apart from another.

The following Waiting Period Exclusions and General Exclusions are pretty much standard in all health insurance policies sold in Thailand.

Pre-existing Conditions: The Company will not pay any benefits for pre-existing conditions i.e. any disease, illness or injury or symptoms (and complications thereof) for which the covered person was treated or knew about which is not completely cured before the commencement date of the first policy, unless the covered person has declared such conditions on the application form and the Company has agreed to cover them without any endorsement to exclude such pre-existing condition.

30 Day Waiting Period: The Company will not pay the benefits for any sickness during the first 30 days.

120 Day Waiting Period (Some companies use 150 Days or 180 Days: The Company will not pay any benefits during the first 120 days from the first policy commencement date for the following diseases:

1 Benign or malignant tumor or cancer or cystic mass
2 Hemorrhoids
3 Hernias
4 Pterygium, pinguecula, cataract,
5 Tonsillectomy or adenoidectomy
6 Stones
7 Varicose Veins
8 Endometriosis

General Exclusions: The insurance policy does not cover the cost of treatment or losses arising from injury or illness (complications thereof) symptoms or conditions arising from the following:

1.) Pre-existing conditions, Congenital abnormalities, growth development abnormalities, and genetic disorders.
2.) Any cosmetic surgery or beautification treatment including treatment of acne, freckles, dandruff, weight reduction and weight gain, hair loss. Reconstructive surgery is also excluded unless injury is sustained as a result of an accident.
3.) Services in connection with infertility, pregnancy, childbirth, abortion or miscarriage, or any causes related to pregnancy, sterilization or investigation of sterilization
4.) AIDS/HIV, related or sexually transmitted diseases (STD)
5.) Treatment to relieve symptoms commonly associated with aging, menopause or precocious puberty, sexual dysfunction or sex change.
6.) Health check ups, convalescent care including rest cures and rehabilitation. Any treatment, drugs or medical supplies which are not related to the diagnosis; and. diagnosis which is not related to the injury or illness or not according to the medical necessity and normal standard.
7.) Eye examination and eyesight corrective surgery including lasik and other expenses associated with eyesight correction.
8.) Treatment or surgery relating to dental or gum e.g. denture, crowns and bridges, root treatment, filling, orthodontic, scaling, extraction, except the necessary dental treatment after an accident. However, the coverage does not include the costs for crowns and bridges, root treatment, orthodontic services.
9.) Medical treatment related to alcoholism, cigarette addition, drug or other addicted substance.
10.) Medical treatment related to the nervous disorders, mental disorder, anxiety, psychiatric problems, personality disorder, autism, stress, eating disorder.
11.) Medical treatment which is in a trial stage or experiment, associated with disease or symptoms of sleep apnea, sleeping disorder, treatment to stop snoring.
12.) Any inoculations or vaccinations, except rabies vaccine needed after an animal attack or tetanus shots needed after an accident or injury.
13.) Treatment which is not considered a modern medicine, including alternative medicine.
14.) Any medical treatment given by a medical practitioner who is the parent, spouse or child of the covered person. The covered person who is a registered medical practitioner may not be reimbursed for any self- administered treatment.
15.) Suicide or suicide attempt, self inflicted injury or attempt of self-inflicted injury whether being his/her own action or allow others to perform while insane or not. This also includes the accident to the covered person due to consuming, drinking, or injection of toxic substance into the body or drug overdose
16.) Any loss or injury arising from the action of the covered person whilst under the influence of alcohol, addictive drugs, narcotic drugs to the extent of being unable to control one's mind. (The term "under the influence of alcohol" in case of having a blood test refers to a blood/alcohol level of 150% mg and over.)
17.) Injury while the covered person is taking part in a brawl or taking part in inciting a brawl.
18.) Injury while the covered person is committing a felony or while the covered person is being arrested, under arrest or escaping the arrest
19.) Injury while the covered person is taking part in dangerous sports or activities including racing of all kinds including car, boat and horse racing, racing of water and snow ski-ing, including jet-ski, skating, boxing, parachuting jumping (except for the purpose of life saving), boarding or traveling in a hot air balloon, gliding, bungee jumping, diving with oxygen tank and breathing equipment under water.
20.) Injury while the covered person is boarding or traveling in an aircraft which has no license for carrying passengers or does not operate as a commercial aircraft.
21.) Injury while the covered person is piloting or working on board as an employee of an airline.
22.) Injury while the covered person serves as a soldier, police, or a volunteer and participates in war or crime suppression.
23.) War (whether declared or not), invasion, acts of foreign enemies, civil war, revolution, insurrection, civil commotion, popular rising against the government, riot, strike.
24.) Terrorism
25.) Ionising radiations or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel.
26.) The radioactive toxic explosive or other hazardous property of any explosive nuclear assembly or nuclear component thereof.

Each of the above provides legitimate grounds for rejecting a claim. So if your claim gets rejected for any of those reasons, you have no grounds to protest or complain about the insurance company. Unless, the relationship between the medical problem and the exclusion is not entirely clear. We recently ran across such a situation.

The insured had a problem in his mouth that required surgery. The insurance company rejected the claim because it was a dental problem and treatment for dental problems is clearly excluded. The original surgeon had given the problem an identity that clearly identified it as dental related. But the problem had nothing to do with his teeth or gums.

He visited a respected oral surgeon in Bangkok and the surgeon wrote him a letter certifying that it wasn't a dental problem. The insurance company stood firm. The insured finally contacted the OIC for help and showed them the surgeon's letter. A meeting was scheduled. Both the insurance company and the insured came loaded with documents to prove that they were each right. The OIC refused to look at the documents and instead ruled in favor of the insured. The OIC reasoned that when there is doubt, the insurance company should payout.

The OIC is on your side. Contact them if you have a "legitimate claim" that gets rejected. They want to help you.

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