What does health insurance cover?
- Treatment costs for illness that is covered under the terms and conditions of the insurance policy.
- Treatment costs for accidental injuries (not self-inflicted).
- In-patient treatment is the minimum required purchase.
- Treatment for pre-existing conditions, only if agreed by underwriters of certain insurance companies.
- Out-patient treatment is options for some insurance policies.
- Treatment costs are consistent with generally accepted standards of medical practice in the country in which treatment is being received.
- Treatment is clinically appropriate in terms of type, duration, location and frequency for that condition.
- The insurance company will only pay for reasonable and customary charges. Costs should not be more than they would normally charge to other patients in the same area.
What does health insurance not cover?
- Treatment costs for pre-existing conditions and related conditions (below items 1. to 6. are all read together as if they are in one sentence).
- Any medical condition or related condition for which you have received treatment.
- Or medical condition that you had symptoms of.
- Or to the best of your knowledge knew this condition existed.
- Or sought advice for this condition.
- Or taken (prescription or non-prescription) medication for treatment.
- Prior to the start date of the insurance policy.
- Accidents while intoxicated or under the influence of illegal drugs.
- Many companies exclude treatment in the USA or limit it to life threatening emergencies and accidental injuries.
Two types of medical underwriting affecting pre-existing conditions:
- Full medical underwriting policies
- The majority of health insurers use this method for screening applicants.
- Medical underwriting requires applicants to honestly disclose all their pre-existing medical conditions.
- Underwriters will review applications and propose the exclusion wording for the customer to accept.
- Only in some cases, can exclusion wording be revised at start of policy.
- Exclusion wording has to be agreed on at the start of the policy, there is very little chance of changing this in the future.
- Changes to exclusions have to be accompanied by medical reports that are acceptable to the underwriters. There is no guarantee that exclusions will be deleted or changed.
- Moratorium underwriting policies
- With moratorium underwriting, after 2 years of continuous cover, some pre-existing medical conditions will become eligible for benefit.
- Many pre-existing conditions will never be covered by a moratorium policy, such as; Diabetes, Hypertension (raised blood pressure), Hyperlipidemia (raised cholesterol levels), Ischemic heart disease, Cancer, Thyroid disease, Auto-immune disorders, Arthritis.
- For a particular condition to be covered, it is required that in the first 2 continuous years of the policy; You did consult any doctor for medical treatment, or take any medication, or suffer any symptoms for that medical condition, or suffer symptoms for any related condition.
- If you experienced any of the above (listed in item 2.), you will be required to wait another 24 months from the last date of treatment and must meet the criteria listed in item (3.) before being allowed to claim for the pre-existing medical condition.
How to use your health insurance:
- Get Emergency treatment first. Call or have someone else call on behalf of you, the 24 hour Emergency number nearest to your location as soon as possible.
- Give your name, policy number, telephone number and location.
- Emergency contact telephone numbers are on your insurance card.
Non-Emergency In-Patient & Day-Patient treatment:
- Call the insurance company as soon as reasonable; or at least 24 hours before admission to the medical center. Some companies require 72 hours notice.
- Provide your name, policy number, telephone number, and location of planned treatment, dates of treatment and the name of the Specialist / Doctor treating you.
- When the insurance company has sufficient information to appraise the claim, written confirmation will be dispatched to you and the medical center will be paid directly.
- If you should undergo treatment before obtaining confirmation from the insurance company, you may not receive a full refund for all expenses.
- If the hospital fails to supply all required information and documents to the insurance company, you may have to pay first and claim back the medical costs later. Original documents must be sent to the insurance company to pay the claim.
- Claims are processed faster if you call the insurance company prior to a claim.
- Certain insurance policies include outpatient treatment; some only have limited outpatient treatment benefits.
- Go to the hospital for you outpatient treatment and pay the bills. Insurance companies will have their own claim form that has to be filled in my both the patient and the doctor.
- Send the insurance claim form and original receipts to the insurance company for a refund.
Switching between different Health Insurances (only if absolutely neccesary):
- Choosing the best health insurance to match your needs is essential.
- Moving between different health insurance companies each year to save on premium expenses is to your disadvantage. It is always advisable to stay with the same health insurer as long as possible.
- As we get older, our bodies develop certain medical conditions. The older we get; the more medical conditions we accumulate.
- Take for example the family that has chosen a cheaper health insurance plan because they expected to stay in Thailand. In the future, due to unforeseen reasons, they have to move away to a different country. The local health insurance will only provide them with temporary cover in the new country (usually 90 days). This family will have to apply for a new health insurance with a different company.
- All new applications will have to declare pre-existing conditions. Certain conditions that were covered by the previous health insurance are now no longer covered. These conditions started during the previous policy year (when they were covered) but cannot be covered by the new policy because they exist at the start of the new policy.
- Your family will not be given a discount on the premium due to excluded pre-existing conditions. Your premium rates will be the same as other policy-holders of the same age- group but your cover will be inferior to others because of declared (and undeclared) pre-existing conditions that are not covered.
- All health insurance companies regard pre-existing conditions in a similar manner. Very few companies will give the customer the choice of cover on a few pre-existing conditions. These companies will cover a few declared conditions at a higher premium fee.
- New applicants that fail to declare all pre-existing conditions on the application form risk either having their policy cancelled when the insurance company finds out at a later date or; if the insurance company is lenient, they will add exclusions to the policy to offset the undeclared pre-existing conditions.