What to do when your claim is not paid
1. Obtain the decision in writing
Ask your insurer to confirm:
- the status of the claim
- the reason no payout was made
- the benefit that was assessed
- the policy clause or exclusion applied
- how the payable amount was calculated
- whether any further information is required
A written response gives you something specific to review and respond to.
2. Check which part of the plan was assessed
For an IP claim, establish whether the outcome relates to:
- MediShield Life
- the additional private insurance component
- the rider
- more than one of these components
A single hospital bill can produce different outcomes under each layer of coverage.
3. Review the policy schedule and contract
Look beyond the product brochure.
Gather:
- the main policy contract
- the policy schedule
- rider documents
- endorsements or amendments
- the insurer’s claim letter
- the hospital bill and claim breakdown
The policy schedule may contain personal exclusions or special terms specific to the policyholder.
4. Compare your insurer’s reason with the MOH categories
Use the stated reason to identify what to examine next.
- When the bill was below the deductible, check the calculation.
- When an exclusion was applied, ask for the exact clause.
- When a pre-existing condition was cited, check which component of the IP was affected.
- When a limit was reached, ask for the claims history used to calculate the remaining benefit.
5. Gather evidence that addresses the reason
Do not simply resubmit the same documents.
Provide evidence that relates directly to your insurer’s explanation. This might include:
- a doctor’s report clarifying the diagnosis or when symptoms began
- earlier medical records
- proof of premium payment
- an itemised hospital bill
- receipts and payment records
- correspondence with another insurer or employer
- the original insurance application and health declaration
Keep copies of everything submitted and note the date of submission.
6. Request an internal review
When asking your insurer to reconsider its decision, state clearly:
- which part of the decision you disagree with
- why you believe the policy clause may not apply
- what additional evidence you are providing
- what clarification or outcome you are seeking
Keep the request factual and focused on the policy terms.
Speaking to your financial representative is also important. He/she could help retrieve policy documents, explain the claims process and follow up with your insurer. Nevertheless, your insurer remains responsible for assessing and deciding the claim.
7. Escalate the dispute when necessary
Give the insurer an opportunity to investigate the complaint and provide its final response.
If the dispute remains unresolved, eligible consumers may approach the Financial Industry Disputes Resolution Centre, or FIDReC. Consumers must first approach the financial institution and generally file with FIDReC within six months of receiving its final reply.
Useful documents for an insurance dispute may include the policy contract and schedule, correspondence with the insurer, bills, invoices, receipts and medical reports.
For an IP dispute involving clinical questions, such as whether a treatment was medically appropriate, the Clinical Claims Resolution Process may also be relevant. MOH describes it as a voluntary avenue for clinically related IP disputes. The parties should first attempt to resolve the matter directly.
Frequently asked questions
Does no insurance payout mean my claim was rejected?
Not necessarily. The claim may have been assessed, but the amount could have been at or below the deductible. Another payer might also have covered the expense, or a claim limit may have been reached.
Why did my IP not pay when I was hospitalised?
Hospitalisation alone does not guarantee a payout. The eligible claim amount must satisfy the policy terms and may be affected by the deductible, exclusions, claim limits and payments from other sources.
Can MediShield Life pay when the private insurer does not?
Yes. MediShield Life and the additional private insurance portion are separate components of an Integrated Shield Plan. MediShield Life covers pre-existing conditions, although the additional private insurance portion may apply exclusions.
Does a request for medical records mean the claim has been rejected?
No. It may mean that the insurer requires more information before completing its assessment.
How long do I have to approach FIDReC?
A consumer should generally file with FIDReC within six months of receiving the financial institution’s final reply. The consumer must first give the financial institution an opportunity to resolve the dispute.
Written by: Great Eastern Lifepedia team
