Page 86 - MEDICAL AND HEALTH INSURANCE

MEDICAL AND HEALTH INSURANCE

5.1.1 DEALING WITH CLAIMS ARISING UNDER MEDICAL AND HEALTH

INSURANCE POLICY POLICIES

Insurance companies have a legal and moral obligation to

pay claims promptly and fulfilling contractual obligations.

NOTIFICATION OF LOSS

It is a policy condition precedent to liability that the claimant must notify the

insurance company immediately of the loss and within 30 days as stipulated in the
policy condition. The claimant must furnish original full supporting documentation,

including the claims form with details of the loss. The claim form will contain the

details of member particulars and period of cover, name of hospital, name of the
attending physician or surgeon, patient's diagnosis and surgical procedure and

treatment received, the related medical history of treatment and probability of

relapse.

CLAIMS REGISTRATION

Insurance company needs to maintain claims register as an official record of claims
notified to the company. This is to make sure that proper and accurate provisions are

maintained, and the claims reserves cannot be removed as long as the claim has not

been settled. Claims must be registered within 7 days in compliance with the
guidelines on claims settlement practices with an acknowledgment letter to be issued

to the claimant enclosing the checklist of all documents required.

CLAIMS ASSESSMENT

The objective of claims assessment is to ensure that the claimant is a covered person
and entitled to the benefit. Other than that, the treatment received is medically

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