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.
Jack was going for a day surgery and consulted his insurance agent on whether the surgery was claimable. He provided the agent with his doctor’s memo and an estimated bill of the procedure. The agent informed him that he could proceed and submit the bill later for claims assessment under his Integrated Shield Plan.
Unfortunately, after Jack filed the claim, he found out that his insurer required him to make a 5% co-payment. The insurer explained that this was because Jack consulted a non-panel doctor. The insurer explained that this co-payment clause for non-panel doctors was a recent addition. During policy renewal, the insurer had informed Jack of the updated policy wordings.
Jack acknowledged that he received the updates to the policy wordings but did not review them. He had relied on the agent to advise him on the claim. Jack felt the agent should have told him about co-payment for non-panel doctor expenses.
Jack filed a complaint at FIDReC. At mediation, the insurer maintained that they had notified Jack of the relevant updates to the policy terms. It was Jack’s duty to read the updates and approach the insurer if he had any issue with the updates.
The insurer also shared that its agents were unable to provide advice on whether a claim would be payable. Claims decisions were made by the claims department after going through claims assessment. In any case, the insurer argued that the agent did not promise Jack that the claim would be payable.
As the parties could not reach settlement, Jack proceeded to adjudication. After hearing the parties and considering all the evidence, the Adjudicator found the agent’s conduct lacking. While the agent did not expressly assure Jack that the claim was payable, he failed to inform Jack that he was unable to provide advice on claims. Instead, the agent merely instructed Jack to proceed with the claim.
The Adjudicator observed that Jack had provided details of the procedure (including the clinic and the cost) to the agent. The agent could have done a quick check to find out whether Jack’s doctor was on the insurer’s panel. The agent should then have informed Jack about the non-panel doctor requirements. The Adjudicator made an award to Jack for the 5% co-payment.
Key Learning Points
Policyholders should not rely on agents to provide advice on whether a claim is payable. Such information can only be provided by the claims department after the claims assessment process.
Before a procedure, some insurers provide the option to receive a pre-authorization. This is where an insurer will provide an indicative assessment on the claim. Pre-authorisations are an optional service, and insurers are not obliged to provide them to customers.
Insurance agents should be clear in their communications with customers. This is especially when they are unable to provide advice or information on certain matters. Being upfront with customers will help avoid misunderstandings and customers feeling misled.
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