Home / Malaysia Insurance Law / Insurance Law Medical Claim Rejected Congenital Abnormalities or deformities including hereditary conditions was the reason of rejection

Medical Claim Rejected (modified 0 times) Daddy BL My son was admitted to RCH in Melbourne last year Sept during our holiday trip due to recurrent of Lung Pneumonia. After discharged, we advised by the doctors in RCH to do further test to determine his immunoglobulin level after being well. We then did a test in October the same year, and the result confirm that my son is dignosed with Agammaglobulinemia. Now the insurance company rejected my son hospitalisation claim for RCH Melbourne referring to Annexure Exclusion Clause that stated the company does not cover any hospitalisation, surgery or charges caused directly or indirectly, wholly or partly, by any treatment or surgical operation for congenital abnormalities or deformities including hereditary conditions. In addition, the insurance company now are counter claiming me for the total expenses paid for Y07. I felt it is not fair because he was admitted due to pneumonia recurrent and we only discovered agammaglobulinemia after Melbourne. Am I eligible for the claim? Opinions are very much appreciated pertaining to my case. 17 Jun, 2009 13:21:57

RE:Medical Claim Rejected (modified 0 times) Johnathan Hi, I noted your message is dated June 2009 but no one has replied yet. I just came accross this thread while googling so im not sure what this website is all about or if a lawyer is supposed to answer your question , or maybe ur not expecting any reply Anyway I have some experience in claim dispute handling and your only strength here is the wording in the insurance policy itself. since they say hereditary, you next step should be in trying to prove its not hereditary.Its not easy but you have to question who decided that the mentioned disease is hereditary? Definitily its not God who decided that, and man can be wrong. are there any cases where the said disease is not hereditary. Maybe the word hereditary may sound strong, but as you go deep into the matter you will realise that not all medical professionals will be op the same opinion that the said disease is hereditary. There is always a place for argument. When you can establish at least some sort of doubt in this area, you can bring it to Finanacial Mediation Bureau. They will be happy to look into your arguement. Then the question is, is it worth the time spent in doing all this? If you need any other info you can e-mail johnathan.wc@gmail.com 25 Nov, 2009 15:34:02

RE:Medical Claim Rejected (modified 0 times) Jesus All insurance contracts are baased on the latin maxim "Uberrimae Fidei" or in English Utmost Good Faith. That simply put, means you have to make full disclosure about all known facts (in this case about your sons medical condition). If your son is an adult then your son should have made the declaration. If you read the policy notes you will find such a requirement within the fine print. Where your son had been diagnosed with a particular condition which became apparent after he was diagnosed with lung pneumonia (that may have been viral or brought about by a pre existing condition) the further examinations when in hospital would have uncovered his pre existing and congenital abnormality. Unless you can prove that at the time of signing the policy and paying for it, your declarations were made in good faith and honestly disclosing all your known conditions in this regard, you may not claim from them. It is quite clear that your son has inherited the condition from someone in the family (father or mothers side). It is further clear that you people knew about it or the risk of its existing within your son but did not disclose it. This is a very common feature of Chinese Malaysians and Indonesians comming to Australia for treatment. They get insured then come here for paid treatment at the expense of the insurance companies. I once advised a company here and am still on their panel when called to act. The other con by the south east Asian Chinese is to bring people with heart conditions and to then complain of breathing problems then get admitted to find what they already knew. Their arteries aree blocked. In Australia the standards are hig. In such circumstances they will not let the patient fly hom and operate. The patient then charges the insurance company. Where the company is run by Chinese executives in Malaysia (which is not uncommon) they give and take from each other in most cases. It is always at the expense of the honset insured who does not make fraudulent claims. Such is the plague which infests Asia like the Chinese. 04 Dec, 2009 05:32:49

RE; MRCP II MADE EASY (modified 0 times) Sarah Lawson This tome is useful for insurance as it details the case histories, medical facts and pitfalls of insurance. It is written by a Harvard trained Physician whilst, in the Univerity Malaya library. Certain claims such as a pre existing condition or if the patient has a predisposition to this condition or if it is congenital such as mitral valve prolapse cannot be claimed. There is the onus paradoxically on the patient to prove that this is not so. Sometimed the doctor may have made an errror in what he has written and the treatment may be disqualified as the patient was not admitted, failure to disclose, premature maturation of the insurance, the kind of insurance ( such a an accidental insurance ) or the use of insurance to perform a general medical check up cannot be claimed. The author is also a Member of the Royal College of Physicians , hence ( MRCP ). It is more like a novel in the style of Crichton, House MD and Robin Cook 01 Sep, 2010 13:29:30

RE:Medical Claim Rejected (modified 0 times) ayan I believe that you can claim for the hospitalization for pneumonia. as to the newly found disease, you have to get a medical history or proof that what your child has is not hereditary or something. I fear though that the disease is really not included in the coverage. Review your policy and get legal opinion. 14 Oct, 2010 02:00:36

RE:Medical Claim Rejected (modified 0 times) ayan Shouldn't there be a lapse period for pre-existing conditions? Even if it does exist, a period of one year being insured should have made it included already??? ______________ insurance chauffeur 25 Nov, 2010 00:50:42

RE:Medical Claim Rejected (modified 0 times) iking This is why I always say , why pay insurance agents commissions? We pay 35-40% commissions of the total premium paid. If I post in detail here, then you guys will say I am trying to sell you insurance. I am not. I am trying to assist everyone here on how to not-to pay commissions to insurance agents without effecting your insurance policy. Email to me if you need more info : insurance_king@live.com.my 07 Jan, 2011 19:20:40

RE:Medical Claim Rejected (modified 0 times) James Profile | Email Standards and regulations for medical malpractice vary by country and jurisdiction within countries. Medical professionals are required to maintain professional liability insurance to offset the risk and costs of lawsuits based on medical malpractice. ====================== James Hood 21 Jan, 2011 16:32:04

RE:Medical Claim Rejected (modified 0 times) Insurance noob Hi iKing, I also faced similar problem here. My case is a bit different. I was admitted due to a acute attack on my gastric. Doctor diagnosed as Acute GERD. But insurance company denied my GL application twice, saying to check for any pre-existing conditions. (Acute case is not affected by previous problem) My claim was pending then due to they found out a false-positive non-disclosure on my hand ganglion. They send me a letter saying that if I din sign the counter offer letter, my policy is no longer active. 26 Jul, 2011 11:15:50

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