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If you have a private integrated shield plan, then you may have the following question,

Does the plan cover me for ______ condition?

In fact, this is the most frequently asked question throughout my entire career. In essence, my answer will always revolve around the following three terms:

  1. Eligible Expense 🧾
  2. Medical Necessary 🩺
  3. Reasonable and Customary 🤕

With this purpose in mind, let’s find out what each term means.

Part 1: Eligible Expense 🧾

In order to be an eligible expense, the bill must fulfil two conditions.

Part 1.1: Scope of Coverage

Firstly, the plan has to state that it will cover the particular condition or treatment. Let’s take AIA HealthShield Gold Max Plan A for example. Under Section 6, it states that it will include coverage for congenital abnormalities. In detail, this coverage is provided for female insured’s biological child from birth.

Part 1.2: Limit of Compensation

Secondly, all integrated shield plans will provide a reimbursement up to the stipulated limit. Beyond this point, the insurance company shall not be liable to compensate for the cost of treatment. Following our earlier example, AIA HealthShield Gold Max Plan A will cover S$20,000 per lifetime for congenital abnormalities. In detail, each child is covered up to S$5,000.

On the whole, an eligible expense has to be within the plan’s scope of coverage and its limit of compensation. Moreover, the eligible expense must be medical necessary.

Part 2: Medical Necessary 🩺

For a medical service treatment to be medical necessary, it needs to fulfil six points:

  • Consistent with the diagnosis and customary medical treatment, service, and/or supply for an illness or injury
  • In accordance with the standards of good medical practice
  • Consistent with the current standard of professional medical care, and proven medical benefits
  • Not for the convenience of the insured or the physician or the specialist
  • Unable to be reasonably rendered out of a hospital (if admitted for confinement) or community hospital
  • Not of an experimental, investigational or research nature, preventive or screening nature
SEE ALSO:  Is MediShield Life enough in Singapore?

All in all, this ensures that you seek the right medical treatment for the right medical condition.

Part 3: Reasonable and Customary 🤕

Finally, an integrated shield plan will provide coverage for cost that is reasonable and customary. There are five points to note to this end.

Part 3.1: Medical Necessary

We have listed the points for medical necessary in Part 2 (above). To sum up, the treatment must be consistent with the diagnosis. Furthermore, it must abide by the standards of good medical practice and professional medical care.

Part 3.2: Standards of Good Medical Practice

Besides, the treatment must fulfil the standards of good medical practice for the care of an injured or ill person. In like manner, this is similar to the point mentioned in Part 2 (above).

Part 3.3: Supervision

Of course, the physician or the specialist must order or supervise the entire treatment.

Part 3.4: Review

All things considered, the insurance company reserves the right to review the cost of treatment. Emphatically, this ensures that it does not exceed the usual charges for similar treatment, supplies, or medical services in Singapore.

Part 3.5: Existence

Lastly, the integrated shield plan will provide coverage if the fee will still exist without any insurance coverage.

Conclusion

In summary, there are three criteria to fulfil in order to be covered by an integrated shield plan. While the terms may seem technical, we just need to ask the doctor one question,

Do we need to seek medical treatment because the condition causes harm to our body?

All in all, these clauses are in place to prevent frauds and abuse of medical facility. After all, most integrated shield plans price their coverage based on the concept of risk pooling. Hence, all of us can save on insurance premium if we use the medical coverage only when it is necessary.

SEE ALSO:  Private vs Public Healthcare Insurance in Singapore

Thoughts of the Day 💭

  1. Do the terms of coverage make sense?
  2. Should you get your own private integrated shield plan?
  3. How do you find our local healthcare system?

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