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Insurance Claim Experience

Claim is an important aspect of purchasing insurance. After all, we purchase insurance to cover our risk, and when in the event the risk happens, we expect the insurance company to pony up, right?

In a claims process, there are a few key areas to get done correctly so that the claims can be paid out:

1. Is it claimable under your policy? If you’d like to claim for private hospitalization allowance, for example, you’d first have to make sure that you have that coverage in your policy.

2. Is the claim listed under an exclusion? For example, maybe you want to claim for a maternity-related illness claim, but this is generally excluded under medical plans. Additionally, you’d want to be sure that it has already fulfilled its waiting period.

3. Are the correct forms used, and have they been filled out correctly and completely?

4. The necessary supporting documents that need to be appended, like the doctor’s report, lab results, MRI/ct scan results, death certificate, etc.

5. Where there is a death involved, does the policy have a nominee stated?

While these requirements might sound lengthy and laborious, they are necessary for the correct claim and the correct amount of claims to be fulfilled. In addition, it prevents the likelihood of fraud, not only to the company but even the insured. Of course, a good agent will have the paperwork sorted quickly as we have just got so used to it.

I have a few memorable claims that I’d like to share, and I both the successes and failures I’ve had so that we can learn from them.

Death claim

A client in Indonesia, unfortunately, passed away this year due to an accident. She bought an investment-linked medical plan from me a few years back, which meant it came with some life insurance. While there were no claims made on the medical side, the life insurance was not too small, and when converted into Rupiah, it became even more sizable.

If the person were a Malaysia resident, the declaration would need only a death certificate and the beneficiary’s account number.

Since the beneficiary was also based in Indonesia, there was a lot more documentation to be submitted, like their IC-equivalent, the passport, the birth certificate to ascertain familial ties, the full works of the bank account including the scan of the bank book and the swift code, as well as getting a few forms and letters signed digitally.

I was told that domestic death claims are done within 3 days, and amazingly, this claim was approved and paid out to the foreign bank account in just under a week.

Medical – angioplasty

The waiting period for heart-related claims is 120 days after purchasing the insurance, which is about 4 months. The client underwent an angioplasty procedure in his 5th month of purchasing the insurance but had submitted that he had gone for a medical check-up in his 3rd month of purchasing the insurance that indicated a heart-related anomaly.

The claim was initially declined because the view taken was that treatment commenced before the waiting period was over.

I read the contract closely and submitted that there was no pre-existing condition prior to taking up the insurance (and had proof to support it), and that when the condition was diagnosed post-taking up insurance was immaterial. Treatments that are done after the 120-day waiting period are claimable.

Of course, I was right and awesome, the claim was approved in full, for about RM 50K.

Medical – government hospitalization allowance

When I joined AIA in 2015, all the medical policies sold then had this obscure benefit called the government hospitalization allowance. Basically, if you were admitted to a government hospital instead of a private one because the bill would be much cheaper compared to going private and you’ve saved AIA so much money, there’s this token of appreciation of RM 100 per day of admission.

Claims for this benefit were very low. After all, everyone prefers going to private hospitals, there was little to no reason why you’d opt to go to a government hospital, except for maybe an emergency. This was true, until covid, where everyone goes to government hospitals.

Thinking that the allowance benefit was a permanent fixture in all policies, I wrongly told clients that their covid admission was claimable, even though they bought a different medical policy.

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