These Medical Insurance products are offered by a variety of companies, mostly international companies. In Health Economics, these products are termed 'private health insurance' or PHI in short.
PHI is good if we can afford it. Most agents will tell us 'buy as much as we can afford', this is true. However, we need to know its limitation. PHI do not cover 'everything'. In most cases there will be a certain payment that patients need to pay. These payments are termed 'copayment' and 'deductibles'. Its beyond the scope of this blog for me to talk about these 2 terms. (of course if anyone out there wants me to explain, then just drop me a note below). Also we need to note that each PHI has its own yearly and policy limit. I shall illustrate an example below.
"John brought an insurance policy from Company ABC. He pays a yearly premium of RM2400 to company ABC and this allows him to have a yearly claimable amount of RM10000 and a policy lifetime of RM100,000. John got admitted to a hospital for surgery. The surgery cost him RM8000. Since his yearly maximum is RM10,000 John thought that he do not need to pay any money to the hospital. He was surprised when the hospital told him to pay RM1600 before he can get discharged."
The above classically described copayment. John was unhappy, for the fact that, despite paying RM2400 yearly, he still need to fork out money for his surgery. Hence, we need to understand our policy before we buy any PHI. The policy may be thick and has many pages, however, it will definitely benefit us if we go through them. If we don't understand, then ask our agents. It is their responsibility and job to explain it all to us. Copayment is classically at 15-20% of total medical bills.
Here is another scenario that I commonly hear.
" James pays a premium of RM2400 for a yearly claimable amount of RM10,000 and policy lifetime limit of RM 50,000. James went for a surgery in hospital ABC that cost him RM8000. However he was asked to pay RM7200 before discharged! James know about copayment, but to his knowledge, copayment is usually up to 20% of medical bills (that is RM1600). James was unhappy and lodge a complaint to the hospital and brought the matter up to Bank Negara Malaysia (BNM). After scrutinizing his policy, it was true that James have to pay RM7200. James was disheartened and felt cheated by his insurance agent".
What happen in James' case is where each surgical procedure has got a maximum claimable amount. This clause is usually stated in the policy. James underwent excision of a swelling on his leg. In his policy, all excision surgical procedure, the insurance company pays only 10% of the procedure cost. In James case, its only RM800 !
Next is another common scenario that I frequently get complaint from.
" Peter, 60 years old has got heart problem. He has irregular heart beat and need to have a pacemaker inserted to save his life. He has got a quite comprehensive medical insurance coverage. He pay a yearly premium of RM4800. This allows him to have a yearly claimable amount of RM20000 and a policy life of RM100,000. The doctor that treated him in the medical centre contacted the insurer telling them that he needs immediate surgery and pacemaker insertion to save his life. It was at night. The customer service agent that ran the call centre told the doctor "do the necessary and file for reimbursement later".
The doctor correctly went on to save Peter's life. The surgery cost RM19000. Part of this cost was for the pacemaker, and this cost RM12000. Peter was fit for discharge 2 days later and it was at this time he had another 'heart attack'. He has to pay for his own pacemaker, the rest (that is Rm7000) will be paid by the insurer. As a retiree, it was pretty obvious he cannot afford to pay for his bills. He lodge a complaint against the insurer for giving the doctor and hospital false information and against the hospital for charging too 'expensively' ."
In Peter's case, his policy clearly states that a pacemaker is not covered. However Peter was not aware of it. The night shift customer service of the insurance company told the doctor to do the needful to treat a patient's life but fail to convey the fact that a pacemaker is listed as part of Peter's policy exclusion criteria. The moral of this story is, again, we need to read our policy well. Usually the 'exclusion criteria' for any policy is stated fairly clearly.
The above three cases are commonly by myself in my work. Of course, those names are just pseudonyms and those figures are 'make belief'. What is important is the moral story behind each of the case.
Healthcare is expensive. The general public do not realize this fact especially when most people seek treatment from public hospital. You can imagine, the little money patients pay (RM5, RM30 or RM500) paid to public hospital for treatment is just the tip of the iceberg. Up till now, the government pays for the public's healthcare. How long can the government sustain it? My next blog, I'll paint this picture a little clearer.
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