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Students from the National University of Singapore Pro Bono Group prepared this guide. The guide is for public education and is not legal advice.

What are Healthcare Insurance Disputes and how do they arise?

Healthcare insurance disputes are disputes between an insured person or the policyholder (the person who buys healthcare insurance) and their insurer (the healthcare insurance company).

They usually arise when the insurer rejects a claim in full or in part. Common examples include:
  • When the policy coverage has lapsed or expired.
  • When the policy does not cover the claimed expense.
  • When the insured has failed to disclose material information to the insurer when purchasing the policy.
  • When the insured’s medical condition existed before the start of the policy.
  • When the insurer considers the treatment not to be medically necessary or appropriate.

What should I look out for to avoid Healthcare Insurance Disputes?

Before buying a health insurance product, you should:
 
  1. Ask questions to understand the type of healthcare insurance product offered.
  • There are many different types of healthcare insurance policies on the market, which offer different types of coverage. For example, hospitalisation and surgical expenses, critical illness, etc.
  • They may also differ in the level of coverage offered. For example, whether a private or public hospital, the class of hospital ward, and the claim amount covered.
  • Crucially, they may also differ with regards to definitions of what constitutes a “claim event”, and the exclusions that will not be covered.
  • Finally, certain healthcare insurance products may be paid from your CPF monies, while others have to be paid with cash.
 
  1. Always disclose any medical conditions that you have. The insurer may reject claims if you did not disclose material information.
  • In an insurance contract, you have to enter into the contract in utmost good faith.
  • If you do not disclose important information in the proposal form, the policy may not be valid. The failure to disclose certain pre-existing conditions might affect your ability to claim under the policy. Insurers may also choose not to sell a policy to you, include or amend the exclusions under the policy, or impose higher premiums.
 
  1. Fill up the proposal form carefully. To avoid mistakes, do not ask someone else to do this. Any errors in the form may have consequences when making a claim.
  • The insurer assumes that all the information provided in the proposal form is accurate.
  • You cannot later claim that you have made a mistake, or that the mistake was due to someone other than you filling up the proposal, including the insurance agent.
  • Even if someone has helped you to fill up the proposal, you have to check that all the information is correct before signing.
 
  1. Review the terms of your policy and familiarise yourself with key terms.
  • Important terms include the premium amount, monthly or annual payment, any changes in payment over time, the exact coverage, the limits, and the exclusions.

What do I do if I am facing a Healthcare Insurance Dispute?

You should first identify which of the following categories of dispute your claim falls under.
 
  1. Dispute between the Policyholder and the Doctor/Medical Institution

These disputes may involve doctors and medical institutions overcharging you, or doctors over-servicing. In such cases, try negotiating with the doctor or medical institution first. If you cannot resolve the dispute, you may then file a complaint with the Consumer Association of Singapore (“CASE”), the Singapore Medical Council (“SMC”) or the Clinical Claims Resolution Process (“CCRP”).

The CCRP is a voluntary process where both parties to the dispute agree to the CCRP panel determining the outcome of the dispute. The cost of the CCRP process depends on who the party is. It is S$50 for policyholders, S$200 for doctors, and S$500 for medical institutions and IP insurers.

The CCRP panel consists of six neutral and independent members:
  • A consumer representative (non-voting member);
  • Three medical specialists from the Academy of Medicine, Singapore (voting members); and
  • Two medical directors from select IP insurers recommended by the Life insurance Association (voting members).

The panel will aim to arrive at a decision in an average of 12 weeks from the time a complaint is filed.

The decision of the CCRP panel is final. Both parties can enforce the CCRP panel’s decision against the other party.
 
  1.  Dispute between the Policyholder and the Insurer

These disputes arise if the policyholder thinks that their Insurer has wrongfully rejected their claims.

If you are an Integrated Shield Plan (“IP”) policyholder, we suggest the following approach:

Step 1: Speak to your insurer first

You should first speak to your insurer to resolve the dispute. If you think that your insurer has treated you unfairly, you can lodge a complaint directly with the insurer.

The insurer usually has instructions on their website on how to make a complaint. You can also contact your representative. The Monetary Authority of Singapore expects all Financial Institutions (“FIs”) to handle all consumer complaints effectively and promptly. You can find your insurer’s contact details using the Financial Institutions Directory.

Before you contact the insurer, you should have a clear idea of what your concerns are and how you would like the insurer to address these concerns. Do provide the insurer with:
  • Your particulars (name, contact number, etc.),
  • Your policy number,
  • The details of your complaint, including what has happened so far, and
  • Supporting documents, including medical reports and invoices (if applicable).

You should follow-up with your FI if you do not get a response from them within 2-3 weeks.

Step 2: Approach FIDReC for Help

If you cannot resolve the matter with your insurer after 4 weeks, you may approach the Financial Industry Disputes Resolution Centre (“FIDReC”) for mediation. There is no cost to consumers to do so.
 
FIDReC is an independent dispute resolution institution handling disputes between consumers and licensed FIs. FIDReC provides a low-cost and effective avenue to resolve problems that cannot be settled directly with your insurer.

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FIDReC adopts a 2-step process.
 
  1. A case manager will mediate the dispute between you and your insurer. If the dispute is not settled by mediation, you can choose to bring your case to the second stage of adjudication.
 
  1. An adjudicator will decide on your dispute based on the facts and merits of the case. If you choose to proceed to adjudication, there is a nominal fee of S$50 (plus GST).
 
Please note these limitations before approaching FIDReC:
  1. FIDReC is only able to assist individuals or sole-proprietors.
  2. Claims that exceed S$100,000 cannot be referred to adjudication unless the consumer limits their claim or the insurer agrees to the higher limit.
  3. You must approach FIDReC within 6 months of receiving the final reply from the insurer to ensure that FIDReC is able to assist you.
  4. Your claim must not fall under the types of claims that FIDReC cannot handle under its Terms of Reference. For example, claims already decided in court or settled privately.

You can find out more about FIDReC's Dispute Resolution Process or file a complaint using the Online Dispute Resolution Form. For more information, please visit FIDReC’s Frequently Asked Questions page or submit an enquiry.

You would need to complete and submit a dispute resolution form to FIDReC for them to assess the dispute. You should also submit to FIDReC details of your communications with the FI, and all other relevant supporting documents.

Do note that the adjudication outcome from FIDReC only binds the FI and not the consumer. This means that if you are not satisfied with the outcome, you can continue to pursue other avenues of recourse. This includes taking legal action.

Or you can approach the Consumers Association of Singapore (“CASE”), the Singapore Mediation Centre (“SMC”), or the Small Claims Tribunal (“SCT”). These organisations handle disputes across all types of products and services.

Step 3: Refer Dispute to CCRP

Where FIDReC notices that the dispute is clinical in nature, the FIDReC case manager may suggest that the parties refer their dispute to the CCRP. Consumers may also choose to approach the CCRP directly instead of going to FIDReC.

Do note that the CCRP is a voluntary process and both parties must consent to it. Mediation is only available at FIDReC and not at the CCRP. The adjudication outcome at FIDReC does not bind the consumer unlike the outcome at the CCRP, and the consumer is free to pursue the complaint elsewhere, such as going to court or to the CCRP.

Step 4: Taking Legal Action against the FI

Resolving healthcare insurance disputes through legal action is usually a last resort. Legal action is time-consuming and expensive. You should get advice from a lawyer before taking legal action. If you wish to engage the services of a lawyer, you can access the Legal Services Regulatory Authority for a list of practising lawyers here.

Or you may also approach the Legal Aid Bureau for legal aid and advice. Do note that you would need to meet the specific prerequisites to do so. Find out more here.

Step 5: Reporting your FI to the MAS

The MAS is a financial services regulatory authority, and handles regulatory breaches or misconduct by an FI.

You should report to the MAS if you encounter:
 
  • Inappropriate or misleading advice;
  • Misrepresentation of (financial) products and/or services;
  • Lack of disclosure in the sales and advisory process; or
  • Suspicion of fraud, cheating, criminal breach of trust, forgery, or other forms of fraudulent accounting or corruption by your FI.

Generally, the MAS is unable to resolve disputes involving:
  • A FI’s pricing policies,
  • Private contractual arrangements between you and your FI, and
  • Compensation that you want from your FI.

To file a report with MAS, click here. For more general guides or information on resolving banking disputes, click here.

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Keywords: Healthcare Insurance