These case studies have been modified so as not to identify any actual cases at FIDReC. They are provided for purposes of learning and are not necessarily indicative of outcomes at FIDReC.


Jane experienced chest pain and consulted a cardiologist. The cardiologist diagnosed Jane as suffering from a blocked coronary artery. The cardiologist recommended that Jane undergo an angioplasty procedure. The medical bill for the entire procedure was $18,000. Jane’s Integrated Shield Plan (IP) covered her Hospitalisation and Surgical (H&S) charges.

When Jane submitted her claim, the Insurer only agreed to reimburse up to $15,000. For the remaining $3,000, the Insurer explained that this was above what was “reasonable and customary”. Jane came to FIDReC for help.

At mediation, the Insurer referred to the Ministry of Health (MOH) Doctors’ Fee Benchmarks for Surgeries (the Fee Benchmarks). The Insurer explained that the cost of Jane’s type of angioplasty procedure was up to $15,000. Under the insurance contract, the Insurer would only cover “reasonable and customary” expenses. The Insurer considered anything above $15,000 outside what was reasonable and customary.

Jane shared that as a consumer she would not know what costs were reasonable and customary. She had bought the Policy for peace of mind and protection. She stated that the Fee Benchmarks were a guideline and not a restriction on doctors’ charges. MOH had themselves stated that the fees charged may differ from the Fee Benchmarks if the treatment had added complexity.

With the help of the mediator, Jane and the Insurer reached an agreement to settle the matter. The Insurer agreed to cover 50% of the disputed sum (i.e., $1,500) and Jane would bear the rest.


Key Learning Points

  • Clauses relating to reasonable and customary expenses are typical in H&S reimbursement policies. This is to ensure that Insurers avoid overpaying. In turn, this protects all policyholders by keeping the cost of insurance low.
  • Even if you have an H&S policy, it is wise to ask your doctor about their fees and charges. Ask if they are in line with the MOH Fee Benchmarks.
  • Other common reasons for Insurers to reject H&S claims include:
    • elective or cosmetic treatments;
    • experimental or non-MOH approved treatments;
    • non-medically necessary treatments; and
    • treatments relating to pre-existing conditions.
  • Policyholders should refer to their policy contracts for all excluded treatments. Do not assume that your H&S policy will cover all types of treatment and costs. If you are unsure whether your policy covers your treatment, ask your Insurer. Your Insurer may have a pre-authorisation or pre-assessment process before you undergo treatment.
  • Even so, take note that all claims are subject to review by the Insurer. The claims will have to go through the Insurer’s claims assessment process.
  • If you are facing a clinical dispute relating to your IP, you may choose to refer your dispute to the Clinical Claims Resolution Process (CCRP). You may read more about FIDReC and the CCRP here. 


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