Insurer sadly denies your medical claim

Nowadays, with the rising medical cost, a cashless admission medical card, but the insurer sadly denies your medical claim. The insurer cheats. Let us dive in to determine why the insurer denies your medical claim.

Firstly, we need to understand the importance of the principle of utmost good faith.
This legal notion, known as uberrimae fides, demands contracting parties act honestly and truthfully and not mislead or hide any critical information for the contract’s success.

Good faith dictates that both parties must disclose all relevant facts to an insurance arrangement. Honesty implies submitting accurate premiums and coverage limits to the insurance company. Expect the applicants to provide all relevant personal information truthfully.

When signing the contract, the insured and an insurer requires all parties to act in good faith. Insurers play a much more significant role than their insured counterparts, bound by the agreement regarding Utmost Good Faith.

Insurer sadly denies your medical claim

The tragic Case of Liver Transplant is highlighted in Singapore.

‘He died not knowing I was pregnant was the headline on Singapore Strait Time on Friday, June 7, 2002. Too much money, too little time: frantic efforts to raise finances for a liver transplant. A donor is available, but a significant delay over cost proves fatal in this case. “Without money or surgery, there is no solution.

I flashed the headlines of a heart-breaking love story across the local paper. A heartless mercenary surgeon had refused to admit a patient admission. Like adding salt to the wound, the insurer declined a so-called cash admission to a local private hospital.

Insurer sadly denies your medical claim


The chronicle of the misfortune began in
The local specialist diagnosed him suffered jaundice zymolysis. The hospital requested him to pay upfront RM5,230.00 for admission. Look here! It was supposed to be a cashless admittance using a medical card. Later, the specialist discovered he suffered from Hepatitis B as the cause of his illness.

Lacking a liver surgeon to perform a liver transplant there, the hospital found a solution for transferring based on the patient’s grave condition necessitated an immediate transfer to a Singapore private hospital, where he underwent a liver transplant.

When he was ready for a liver transplant, he transferred the patient to another private hospital in Singapore. The donor was the late patient’s older sister, who gave her liver for her younger sibling’s transplant as a tribute of love to her brother.

Insurer sadly denies your medical claim

With no money, there will be no surgery.

“Before the surgeon can execute the surgery, you must first locate a suitable liver donor and then pay a deposit of S$300,000 in full.” According to the hospital, “No money, no surgery” was the policy of the second private hospital in Singapore.

Insurer sadly denies your medical claim
Insurer sadly denies your medical claim

The patient’s family disposed of their share, gold, and jewelry and even borrowed money from distant relatives to save him. They had enough cash in hand; they deposited the hospital. The hospital admitted her as a donor to the hospital for a liver transplant.

Misfortune befalls the family; that morning, the Lord called her youngest brother’s life to an end since he could no longer hold on.

Whatever has passed is ash to ash, dust to dust, but the living must carry on. The deceased family submitted a claim with the general insurance company for an amount insured of RM75,000.00 for the medical card claim. The surprising response from an insurance company.

Insurer sadly denies your medical claim

Ineligible for Claim

Insurer sadly denies your medical claim
Insurer sadly denies your medical claim

It is with deep regret the insurer informs you that the medical expenses for the treatment of your condition are not claimable under the following policy exclusion:

General Exclusion (11) – “suicide or attempted suicide, self-inflicted injuries, self-destruction or any attempt thereat while sane or insane. “

General Exclusion (9) – “… treatment of alcohol dependence syndrome and drug addiction/abuse.”

There was no resolution after numerous visits to the lawyer appointed. On the other hand, the lawyer demanded RM2,000 from the family just to get started. For two years, there was no hearing from the session court.

At the same time, many friends helped the deceased family write many appeal letters to the Malaysian Mediation Bureau or Ombudsman for Financial
Services. All the attempts failed.

A coincidence meeting at the shopping mall, I pumped into a lady giving me a stern glance several times,

At first, we didn’t realize we had previously worked together until I accidentally ran into his sister by accident. We talked over for a cup of tea.

“Jamin wong, can you help me get the case for my late brother. I need your help.”
“When we separated the factory export department, I was confident that you were still pursuing your studies in Chartered insurance, and now it is time you would be able to aid me.” She begged me to listen to her.

Insurer sadly denies your medical claim

“Sure, it’s my pleasure to assist people who have a genuine claim, but those lawyer’s correspondence letters, please do not give to me. I want the proposal form, cover note, policy jacket, and rejection claim letter reply from the insurer.

I will study the case within two weeks and give you a reply If I have a 90 percent chance of winning, I shall write an appeal letter on your behalf to the Bank Negara Insurance Mediation Bureau. Is that alright with you?

Even though it mentioned Hepatitis B in the brother’s proposal form, the insurer issued no exclusion on hepatitis b. The insurer did not include an exclusion clause in the renewal notice. for hepatitis B. After carefully reviewing the liver specialist’s diagnostic report, the patient died of abrupt liver failure due to Hepatitis B, not consuming slim tablets. The deceased is taking slimming pills prescribed by general practitioners.

Insurer sadly denies your medical claim

The insurer did not uphold the utmost Good Faith.

Insurer sadly denies your medical claim
Insurer sadly denies your medical claim

In the proposal form, the insured had the duty to disclose that he was a hepatitis B carrier, which he had done in good faith. The veteran general insurance agent stated; that he had Hepatitis B, and the underwriter accepted the offer without any exclusion on Hepatitis B. As a result, the insurer did not honor their obligation of the utmost good faith.

The End Is Sweet

In the appeal letter, I highlight only one A4-sized piece of paper in the grey area.

After inspect the appeal letter and all the reason I gave, the bureau confirmed the insurer needs to pay the entire medical claim. A happy conclusion, of course. The insurer sent the widow a check for RM75,000 on July 30, 2004.

The insurer doesn’t cheat the public but finds a loophole to deny your claim. Please  read carefully and understand the acceptable tiny printed wording. Before accepting the offer, the is a cooling period of 14 days. If you doubt an unflavored term, request to amend it accordingly.

In any insurance, the best is don’t hide the fact and reality from the insurer. Like in the case of medical insurance, declare your pee-existing illness, for instance, hypertension. You orally take the pill daily but tell the agent not to write the actual scenario.
As a part of the contract, you do not practice utmost good faith; the insurer can void the warranty and deny your claim. You are buying insurance for the peace of mind, not giving you a hard egg later. Beware, don’t naively treat the insurer as a dummy.

The insurer paid a small claim but denied a more significant claim. We’ll see how the insurer breaks the tenet of utmost good faith in the next episode.

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Never Trust what the bank says about insuring a house loan

Never Trust what the bank says about insuring a house loan.

Never trust what the bank says about insuring on a house loan on fire insurance. Don’t take the bank for granted. Let us dive in, looking at two different scenarios.

After signing the Sale and Purchase agreement with a developer with a ten percent deposit for a two-floor terraced house, a young newly wedded couple was over the moon.

Never Trust what the bank says about insuring a house loan

The bank officer says they need to take ninety percent of the housing loan on fire insurance. They duly agreed on the sum insured, i.e., $270,000.00

As they are young and still paying the education loan, they move into the new house without any major renovation, just ten thousand on a kitchen cabinet, and purchase some simple electrical appliances. They enjoy the new environment with friendly neighbors.

Never Trust what the bank says about insuring a house loan
Never Trust what the bank says about insuring a house loan

The house blazed to the ground due to some illegal wiring tampering, overloading of the current supply, and a short circuit. Like most laypeople, they thought that the insurer would pay them $270,000.00. The final settlement of the claim was only amounting to RM200,000.00. Why is that so? They are puzzling, and gossip about the insurer cheated their money.

Never Trust what the bank says about insuring a house loan

Another businessman took a fifty percent margin of financing his semi-detached house purchased from a developer valued at one million dollars. He signed for the half-million dollars fire insurance from the bank.

It was such a coincidence his house was next lane to the newly wedded couple. This businessman spent another half-million on an extensive renovation to befit his social status. Indeed, a wise man took up another half-million-dollar fire insurance from his closed associated with another insurer.

Never Trust what the bank says about insuring a house loan

After the fire broke out, his house was gazed to ash due to the hot, dry summer.
The bank insurer settled his claim for Three hundred fifty-five thousand only.
As for the renovation brought from his associated for renovation, the payment was the total amount.

The same bank, insurer, and exact location make the vast difference in claim settlement.

Here is the crucial principle of insurance. i.e., indemnity.

According to the indemnity principle, an insurance policy cannot compensate policyholders for more than their actual financial loss. If the policyholder’s financial situation had not been affected, they would get a benefit equal to the amount of the loss.

The principle of indemnity ensures that the insured will be compensated for their losses but will not profit from an accident or claim. You won’t get anything less than what you need to get back on your feet.

Never Trust what the bank says about insuring a house loan

In the first case, the bank over-insured the house for the young couple, whereas in the second case, the house was under-insured. Who is the intermediary for the insurer that none other than the bank wrongly advises their client? A lesson learns, don’t the what the bank word as gospel.

In a nutshell, it is simply common sense that the land property can burn the land to the ground when a fire breaks out. Firstly, we should go minus ten percent of the total purchase price as a rule of thumb.

Secondly, what is the profit margin of the developer? It all depends on the location and type of material used in constructing a building. It varies from twenty to forty percent of the total purchase.
Let us assume that 30% is the developer’s profit margin, i.e., ninety thousand. The actual sum insured would be two hundred and ten thousand only.

Never Trust what the bank says about insuring a house loan

Let us put it another way, if, after two years, the young couple decides to sell their nest for half a million, the new owner still must insure for two hundred and ten thousand only (assuming no inflation here). The insurer would ignore the market speculation to reinstate the burnt house as before. Indemnity would ignore the profit gain element.

In the second case, the insurance average law applies here. It is a clear cut under insurance. 500,000 over 700,000 x 100%= 71%. Thus, the final claim is 500,000 x 71%= 355,000.

Never Trust what the bank says about insuring a house loan
Never Trust what the bank says about insuring a house loan

It is always advisable to purchase another policy for the extensive renovation work—the bank has no interest in covering your extra out-of-pocket money. Like fits the iron grill or stainless-steel auto gate.

Never Trust what the bank says about insuring a house loan

As for the home content, cover fire and thief under householder or home content policy. If you hire a maid at home, it is better to ensure a full thief policy instead of an ordinary burglar policy.

Don’t forget to add a rental clause even if the owner occupies their own home. If the house gazed to the ground, you need to rent a similar place for two years before getting a newly completed house.

Likewise, it is the same for non-owner occupied. Perhaps, you rent it out. No rental collects after a fire. The amount would be how much you need to rent a similar home. If it is one thousand dollars a month, add twenty-four dollars as the sum insured.

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As always, please leave any ideas or questions in the comments area below.