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Understanding Medical Insurance

Tips on making claims

1. Be aware of the deadline for lodging a claim

Medical insurance policies usually have a time limit for lodging a claim, normally within 30 to 90 days from the date of consultation or discharge from hospital. Insurers have the right to reject claims submitted after the deadline. You must initiate the claim with relevant supporting documents within the time limit.

Some insurers offer pre-authorisation services. This means that the insurer settles the pre-authorised bill directly with the medical organisation, so the insured person does not have to pay the bills upon discharge from hospital. You should apply to the relevant insurer for this service, according to the time limit stated in the policy and prior to hospital admission. You will need to bring along the pre-authorisation confirmation or letter of guaranteed payment at admission. However, it is important to note that the pre-authorised amount is only a preliminary assessment, and may be different from the final costs. The actual claim payment is subject to the final claims decision made by the insurer. If you are in doubt, please contact the relevant insurer directly.

2. Prepare the required documents

For reimbursement of relatively low medical costs, such as outpatient claims, you are normally required to submit a claim form together with the official receipts and original copies of referral letters (if applicable). Some insurers allow submission via e-platforms. For hospital claims, the following documents are also normally required:

  • A claim form completed and signed by the attending doctor and stamped by the hospital;
  • Original hospital receipts;
  • Copies of diagnostic or laboratory reports;
  • A discharge summary and sick-leave certificate with diagnosis if hospitalised in a public hospital; and
  • A copy of the police report, traffic accident report, or police statement if you were involved in a traffic accident.

If you plan to lodge a claim with more than one insurer, ask your attending doctor to complete the claim forms provided by the different insurers and get the hospital to stamp all the forms. After making the first claim, ask the insurer concerned to send you back the original receipts or certified true copies of the receipts, so that you can make a second claim with the original receipts or the certified true copies.

3. Understand what “medically necessary” means

Some people misunderstand what counts as “medically necessary”, believing that hospital claims will be accepted if their hospital admission was referred by a doctor. In fact, a referral by a doctor is not the sole factor constituting “medically necessary” as defined in a medical insurance policy. The definition of “medically necessary” varies amongst different policies, but most insurers share a few common grounds. These include urgency of the condition, urgency of the hospitalisation, necessity for in-patient medication or surgery, feasibility or difficulty of outpatient treatment, and whether the hospitalisation is solely for diagnostic scanning and does not involve administering medication.

In other words, if the condition can be properly treated on an outpatient basis or if no medication is administered during the hospital stay, insurers may reject the claim. To avoid unexpected out-of-pocket expenses, consult your insurer about the coverage and exclusions of your policy before any non-urgent hospitalisation.

4. Understand the “reasonable and customary” clause

Sometimes a significant price difference can be found for the same treatment provided by different medical organisations or doctors. “Reasonable and customary charges” is one of the principles insurers follow when handling claims. In general, insurers make reference to relevant information from private hospitals and healthcare facilities, as well as claims statistics and other sources, when determining the amount of a claims payment. In other words, if the claimable amount exceeds a “reasonable and customary charge”, the insurer may not offer full reimbursement of the covered items. The insured person will have to pay the shortfall. To avoid a claims dispute, you are advised to compare the prices for the same treatment charged by different organisations or doctors or consult your insurer directly before accepting the treatment.


The above information is for reference only. For the coverage, mode of compensation, benefit limit and premium levels of any specific medical insurance plan, please refer to the relevant policy terms.