KUALA LUMPUR: It is not enough to be genuinely and critically ill to get your insurance claims approved, as many people have found out.
The criteria that insurance companies set are strict and technical and, according to aggrieved policyholders, difficult to understand.
Some with heart diseases were taken aback when told that they must have at least three arteries blocked a minimum 70% for their claims to be approved.
One policyholder, Raymond (not his real name), who was confirmed to have had a heart attack by his cardiologist, was perplexed when his claim was rejected.
His insurer referred him to a condition of the policy that people who had a heart attack must “fulfil the criteria ... (of) having a history of typical prolonged chest pains, death of a portion of the heart muscle, new electrocardiogram (ECG) changes resulting from these occurrences and elevation of the cardiac enzyme above the generally accepted laboratory levels of normal before their claims can be approved”.
Raymond, an executive in his late 40s, had chest pains for three days before he went to a private medical centre for a check-up.
The cardiologist did a Troponin T enzyme blood test and several other tests to ascertain if he did have a heart attack.
“The blood test was positive and the doctor asked me if I wanted to do an angiogram to confirm the result and to find out the cause.
“An angiogram was done and a stenosis (narrowing) of more than 90% was found in the left circumflex artery and an angioplasty was done immediately,’’ he said.
The doctor then filled the insurance claim form and noted it down as “a heart attack”.
However, the insurance company rejected the claim, saying that the ECG done did not show new changes and the doctor did not do the cardiac enzyme test and instead relied on the Troponin T test.
Raymond said the cardiologist wrote to the insurance company and attached articles from medical journals explaining why the Troponin test was preferred to the cardiac enzyme test.
“Articles on why the ECG did not show any changes was also forwarded but the insurance company refused to take into account that when a rest ECG is done there is a high chance that it would not show any changes,’’ he said.
“My cardiologist was surprised and disturbed by their response.”
Raymond has since lodged a complaint with the Financial Mediation Bureau and his case is being investigated.
Another policyholder, Vijay, a researcher in his 50s, was worried that he would have problems with his insurance claim.
“I had a heart attack recently and doctors found that two of my arteries were blocked while another was partially blocked.
“According to my critical illness insurance policy, I must have three blocks to make a claim,” he said.
He added that he had been admitted to hospital again last month with chest pains.
“If my claim is rejected I will have problems footing my medical bill,” he said.
An insurance agent, who only wanted to be known as Ricky, said that approval or rejection of insurance claims were “strongly based” on the report of the attending doctor.
“There have been some instances when the report of the attending doctor was unclear, thus leading to the insurance claims being held up or rejected,” he said.
Source: The Star, 27 Jan 2012