Johnny Chan

Who's to blame?

Always understand the terms and conditions of a health insurance policy


When you purchase health insurance in Thailand your satisfaction with the product can be affected by number of sources, not just the insurance company. Although, the insurance company is the one who normally gets the blame.

There are actually 5 entities that can have an effect on your satisfaction with your insurance:

1. The Office of Insurance Commission (OIC) - (Formerly the Department of Insurance.) This is the governmental organization that oversees the insurance companies and protects the insurance buyers.
2. The Insurance Company you are insured with.
3. The Agent/Broker you buy your health coverage through.
4. The Hospital you seek treatment from.
5. You, the insured.

I often read complaints about the standard exclusions found in the Terms and Conditions (T&C) of a particular insurance company's policy. What the complainers don't realize is that these exclusions are in all health insurance policies and are mandated by the Thai government's Office of Insurance Commission (OIC) to help protect the insurers and to help hold the cost of health insurance down for insurance buyers. The OIC's job is also to protect and assist insureds when needed. An example of that protection follows:

One of our clients was traveling overseas when cysts in his mouth started becoming painful. He sought treatment to have them removed. When he returned to Thailand he filed a claim for reimbursement. Unfortunately, the doctor who had treated him identified the problem in a way that related it to teeth and gums. Since dental treatment is excluded, his claim was rejected.

To make matters worse, he needed to have more cysts removed after he returned to Thailand. I suggested that he contact the OIC. He and the insurance company then met together with the OIC. He brought in support from his treating physician, a specialist at a 1st class hospital in Bangkok.

The insurance company came loaded with support for their position from various authorities around the world. Both sides showed that they were correct to some extent. The OIC then decided that because of this doubt, the insurance company would have to shell out and pay the insured's claim.

The insurance company that you are insured with, no matter which one it is, has had a lot of experience with people who are trying to take advantage of them by purchasing insurance to cover treatment of medical problems they already have. The people processing your application, or your claim, are hired to find and weed-out these people. Their job is to help save the insurance company money from costly invalid claims.

One of the most blatant attempts I've encountered of someone seeking treatment for a pre-existing condition was the time I received a health application on a Friday and then received a call from the applicant the very next day wanting to know his policy number. He was in the hospital for an operation. He had actually scheduled the operation before he had submitted the application. This guy wasn't really devious, he was just stupid

The agent/broker you buy your health coverage through. What? You don't purchase your health insurance through an independent third party? That is not very smart. It doesn't cost any more to deal through them and they are in a better position to assist you when you need help.

Of course, you need to be careful when selecting an agent/broker. Even when you purchase through a broker, though, you can still pay your premiums directly to the insurance company, if you want. And, if you are unhappy with what the agent/broker tells you can still double check with the insurance company, or even switch over to another broker. Be careful, but don't be stupid.

The hospital you seek treatment from can sometimes to be the cause of your problems with the insurance company. Hospitals and insurance companies don't like each other. This is because hospitals sometimes want to charge for "unnecessary treatment" or bill for the use of costly new testing equipment. Insurance companies refuse to pay more than they feel is necessary. This upsets the hospitals.

Sometimes delays in getting released from the hospital are blamed on the insurance company. Every time we have checked on the reason for the delay, at the request of a client, it turned out to have been caused by the hospital's filling out of the paperwork for the insurance company. That's reasonable. But, the insurance company's part actually only takes about 10 minutes once they receive the paperwork by fax (It's called a fax claim).

You, the insured should read the terms and conditions of your policy. If there is something that you don't understand, or disagree with, check with your broker. Disagreements with the insurance company should be discussed with your broker.

If your broker doesn't help you, check with the insurance company. If you disagree with their handling of a claim, contact the OIC. If you are in the right, the OIC will help you.




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