Puzzled by insurer's payout for medical claimThe above was written by a disgruntled medical policyholder by the low payout of the medical bills by NTUC Income and this was published in the forum section on the Straits Times last month. Someone by the name of paufurhs has given an excellent breakdown of the medical bill on the ST forum and why the insurer reimburse only $240 back and this is explained below.RECENTLY, my wife was hospitalised at Mount Alvernia Hospital for four days. Her medical bill came up to $7,995.15.
She is insured under Income's IncomeShield Plan MA, but the total payout by Income was a shocking $240.
I called Income to find out how it arrived at that sum and was told that technically the $7,995.15 was classified as "room and board", hence limiting the claim.
The $7,995.15 included a renal screen, bed charges, clinical consumables and supply, diagnostic imaging services, equipment use, laboratory services, outside hospital services, pharmacy cost, resident medical officer fees, treatment fee and doctor attendance fee.
Given a deductible of $4,000 per policy year and 10 per cent co-insurance, any man in the street would expect an insurance payout of $3,595.63. But this is not the case.
My wife has faithfully paid her premium for the past 15 years without a single claim and this is what she gets in return. I am writing this so the public is made aware of such pitfalls in their medical insurance.
For big insurance companies to cite a technicality as an excuse not to make a decent payout is in no way fair. I urge the Consumers Association of Singapore and leaders in the insurance industry to look into this loose definition of "room and board".
In my opinion, given my wife's good record, Income should honour the $3,595.63 payout as a goodwill gesture.
Lastly, I would like to ask the Central Provident Fund Board why only $450 a day can be used from Medisave for hospitalisation.
Ong Kok Lam
In all "shield plans", regardless if it is CPF Medishield or the private shield plans from private insurance companies, "Room & Board" is broadly defined as expenses including meal charges, professional charges, investigations and other miscellaneous charges. In short, in includes any inpatient medical charges not relating to surgical expenses.This is not the first time I have seen this type of cases appearing on the ST forum. The one thing that is rather similar in these cases is that one thinks that as long they have a medical insurance plan such as Medishield, they are entitled to a stay in any type of wards in any hospitals and they expect a large part of the medical bills to be reimbursed back through the medical insurance plan. Unfortunately, this is not true. One has to match the correct plan with the correct class of ward. In this case, the Incomeshield Plan MA which was originally the Medishield Plus A, ran by the CPF Board, is geared towards the coverage of bills in an 'A' class ward and below in a restructured hospital and Mount Alvernia Hospital is a private hospital. Another point is that this plan is not an 'as charged' plan and thus there are limits to the claims for each category. As such, do make sure that you know what you are entitled to under the medical insurance plan which you have subscribed to and in the unfortunate event that you need to be admitted to a hospital, choose the correct class of ward and hospital.
In the gripe letter, and from the description of the expenses, it is very obvious none of the expenses are related to surgery, and so they fall under one category - "Room & Board".
For those who can't figure out how a $7K+ bill can only be entitled to only a $240 reimbursement amount, I breakdown the calculations.
All "shield plans" are integrated with CPF Medishield, thus forming a 2-tier medical insurance plan. During claims, the insurer will calculate which tier will reimburse the most of the expenses incurred, and pay out from that tier.
Incidentally, FYI, a part of the "shield plans'" premiums are paid to CPF Board for the respective Medishield tier.
The bill incurred under the alleged "Room & Board" category was $7,995.15
The limit of claim under the Incomeshield MA tier is $690 per day.
Since patient was warded for 4 days, the max. claimable amount is $2,760.
The established deductible under this tier is $4,000.
As the claimable amount is below the deductible, there will be no payout under this tier of coverage.
Move this $7,995.15 to the Medishield tier.
The limit of claim under the Medishield tier is $450 per day.
Since patient was warded for 4 days, the max. claimable amount is $1,800.
The established deductible under this tier is $1,500 (for B2 ward and above, and for claimable amount between $1,500 to $3,000).
Therefore, the sub-balance after deductible would be $300 ($1,800 - $1,500)
(At this point of calculation, the patient must already bear $7,695.15)
The established co-insurance under this tier is 20% (for B2 ward and above, and for claimable amount between $1,500 to $3,000), which is computed as $60.
Finally, the reimburseable amount under this Medishield tier is $240 ($300 - $60)
The patient bears $7,755.15 ($7,695.15 + $60)
Since the CPF Medisave Account can only be used to pay $450 per day for non-surgical inpatient bills, the patient can only use $1,800 from Medisave to pay for the hospital bill.
The remaining $5,955.15 has to be paid in cash.
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