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28 Januari 2012

Aku dan Polisi Insurans

Muka depan TheStar semalam.
Laporan khas tentang syarikat2 insurans di Malaysia.
Mereka semakin rigid dan teliti tentang coverage mereka.
Banyak sangat kes yang ditolak mentah2.
Sebagai pembeli insurans kena baca dan faham betul2 polisi yang dibeli.
Sebagai doktor pun aku pening kepala baca polisi insurans.
Apatahlagi orang2 kebanyakan.
Yang menjual insurans pun bukannya arif sangat.
Masa nak jual semuanya boleh cover.
Tetapi bila dah terkena baru tahu banyak yang tak boleh cover.
Beli insurans bukan macam beli ikan di pasar.
Pilih, tawar harga dan bayar.
Beli insurans kena ada komitmen.
Bertahun2 kena bayar.
Ribu2 setahun pulak tu.
Beli insurans bukan sebab agen tu kawan baik.
Beli insurans bukan sebab agen tu saudara-mara.
Beli insurans ikut keperluan bukan ikut kata kawan.
Beli insurans ikut keperluan bukan ikut kata saudara-mara.
Tak rugi tanya soalan macam2.
Tak perlu malu untuk tanya soalan2 bodoh
sebelum diperbodohkan kemudian hari.
Kalau isi borang cuba isi sendiri.
Kalau tak faham tanya.
Kalau perlu isytihar sakit yang dulu2,
jangan cuba selindung2.
Jangan dengar cakap agen bulat2.
Istilah Heart Attack dah makin spesifik.
Kena ada perubahan nyata pada ECG,
kena ada confirmation dengan ujian darah.
Kena sumbat ketiga2 salur darah,
kena sumbat lebih 70%,
barulah boleh confirmed Heart Attack,
barulah boleh claimed dengan pihak insurans.
Sekarang ni pihak insurans sentiasa cari kesilapan teknikal.
Sejarah penyakit yang lepas2 walaupun tak seteruk mana,
terutamanya kencing manis atau darah tinggi,
mesti jadi hal untuk gagalkan tuntutan.
Jadi sebelum sain apa2,
baca dan fahamkan polisi dulu.

Hundreds of true-life trials of the insured

> Reports by LOURDES CHARLES, DALJIT DHESI, STEVEN DANIEL and AUSTIN CAMOENS

PETALING JAYA: Disputes over health insurance claims are fairly common, judging by the number of cases handled by the Financial Mediation Bureau.
In 2010, the bureau heard 251 cases and ruled 142 in favour of policyholders and the rest for insurance companies. The following are a sampling of the cases:

CASE ONE
A policyholder suffered an acute heart attack and an emergency coronary artery bypass surgery was performed. His medical report stated that he had been having mild diabetes for about two years.
The insurers rejected his claim on the grounds that the hospitalisation arose from diabetes and related complications. They based their decision on medical findings that diabetes is a risk factor for coronary artery disease. The attending doctor, however, said the heart attack was not due to his diabetes. The consultant cardiothoracic surgeon reported that the risk factors for the insured’s heart disease were smoking and high cholesterol.
The mediator held that the exclusion clause was not applicable and the insurers were liable to settle the claim.

CASE TWO
An insurance company had rejected a hospitalisation claim that a policyholder made following a cataract surgery. It contended that the surgery had been done on an out-patient basis at the eye surgical centre. The insured argued that he was admitted to the Mount Elizabeth Medical Centre and was there for eight hours and that the eye clinic was based in the hospital.
The bureau found that the eye surgical centre was part of the registered hospital and the insurance company was liable to settle the claim.

CASE THREE
An insurance company declined to settle the death claim of an insured mother who died.
The insurance company alleged that the mother was not covered under the policy. However, the insured argued that she had included both her parents at proposal stage and had been allowed to renew the same conditions yearly.
The company re-checked its re­-cords and discovered that the insured had actually taken two separate policies: one for her and her spouse and the other for her parents.
The insurance company agreed to settle the claim.

CASE FOUR
A woman was hospitalised for breast hyperthrophy (extreme breast growth) and underwent breast-reducing surgery. The insurers rejected her claim on the grounds that the surgery was cosmetic.
The bureau drew their attention to the diagnosis of the doctor that the surgery was a form of treatment and not for cosmetic purposes.
The insurance company settled the claims.





4 ulasan:

  1. Assalammualaikum Dr,
    Mintak izin share artikel paper tu boleh yek?
    Nak ajar sikit insurans ni,masa beli insurans mcm2 dia kata boleh cover.dah beli,dental pun tak cover katanya..

    BalasPadam