MOH, MAS to tighten watch on IP insurers over unfair claim rejections

Singapore

THE Ministry of Health (MOH) and the Monetary Authority of Singapore (MAS) will tighten surveillance over integrated shield plan (IP) insurers to protect policy holders from any unfair claims assessment.

This comes after Aviva Singapore's move in March to stop claims for diagnostic endoscopies - which are frequently performed to diagnose many conditions, including common cancers - under its IPs drew concern from doctors and industry watchers.

IP insurers are required to seek approval from MOH for changing their IP terms and conditions (T&Cs).

In a joint statement on Thursday, MOH and MAS said they have engaged Aviva, which clarified that it did not change its IP T&Cs.

Aviva claimed it had tightened its claims assessments, after having observed a "trend of questionable claims".

But this tightening resulted in claims being rejected despite being "medically necessary", said MOH and MAS in a forum letter responding to an op-ed published in The Straits Times.

Aviva has since reinstated its coverage of diagnostic endoscopies since August and will be initiating revised claim settlements for such endoscopy claims that were rejected between March and August.

Following the matter, MOH and MAS said both agencies will "enhance surveillance efforts so that inappropriate practices can be identified and dealt with more expeditiously".

They will also look into providing guidance on determining the medical necessity for specific procedures, and requiring insurers to incorporate this guidance into their claims assessment.

MAS said it will take action against insurers if they do not pay claims in accordance with policy T&Cs or have unfair claims-handling practices.

In a recent op-ed, public health specialist Wong Chiang Yin said an IP policy holder who may have paid his premiums can be worse off than a person who relies only on MediShield Life (MSHL) for healthcare coverage, if IP providers can unilaterally decide on what to cover.

But MOH and MAS clarified that an IP policy holder would not receive a lower payout than a person only covered by MSHL, as IPs provide additional coverage above the MSHL component.

IPs comprise two components - an MSHL coverage run by the Central Provident Fund Board, and an additional private insurance coverage component run by private insurers, typically to cover Class A/B1 wards in public or private hospitals. MSHL is a component of IP; there is no duplicate coverage.

To ensure that health insurance remains affordable, patients should refrain from over-consuming healthcare; doctors should prescribe only treatments that are medically necessary; and insurers should assess claims carefully to minimise over-consumption without compromising necessary healthcare, said MOH and MAS.

"MOH and MAS will step up engagement with clinicians and insurers to strengthen good practices that will help ensure appropriate and affordable care."