Do your homework before signing up

We do not need a consumer advocate such as Michael Moore to tell us that claiming on a health or accident insurance policy can be a hassle. Although most claims are processed smoothly, many experience difficulties. That however can be easily prevented. Here is how.

Being prepared is half the battle won, so the saying goes, more or less.

Choti, a doctor, recently injured himself on two separate occasions within two days. He tried to claim compensation for the two incidents, but his insurance company would not hear of it. "They said the accidents had happened too close to each other to be considered two distinct incidents," he said. The compensation was so minor that he did not really bother to go through the small print.

Here lies the cardinal sin of the insured.

Faced with confusing legal language in their policy contracts, consumers must be persistent in asking their insurance agents or companies about the details of their coverage, down to the very small items. This can make or break a claim.

"With health and accident insurance coverage, most people tend to look at it as a single item and forget to look at the details," said Patcharee Ayuwattanakul, Ayudhya Allianz CP Life Insurance's vice president for claims.

When looking for the right coverage, consumers need to go down the list of items and look at, for instance, how much the policy will pay for your room rate and food if hospitalised, she said.

As the Thai insurance industry moves away from agents and concentrates on alternative, faceless distribution channels such as telemarketing and the Internet, consumers must actively educate themselves about various policies and keep abreast of new developments. Many insurance companies have set up call centres for this purpose, and their websites are usually updated regularly.

"Many times customer complaints are caused by the claimant simply forgetting about what the insurance policies actually cover," said Patcharee. Any assumptions must be banished.

Inflation will, for instance, send hospital room rates up and force customers to pay the difference. "Consumers must do their homework," said a line manager in a top-five life-insurance company who wished not to be named. She said many of the complaints she came across stemmed from customers having unrealistic expectations.

She suggested that prospective policyholders examine all costs associated with the hospitals in their areas or the ones they usually go to, scrutinising expenses from doctors' fees to surgical fees right down to food prices, and budget accordingly. It is possible that what looks like coverage of Bt500,000 may only allow for a Bt30,000 claim in surgery.

For convenience, they should also make sure that their hospitals of choice have contracts with insurers.

"They should also come clean when asked to disclose their previous illnesses and medical history, since many policies will not pay for sicknesses contracted prior to the policy becoming effective."

Choti once witnessed a patient's family being denied a Bt100,000 claim upon the sudden death of a parent. He said the deceased had not undergone a physical check-up and did not know that five months into his insurance purchase he would die from final-stage liver cancer. This is an integral part of scrutinising the contract and questioning insurers about the exact coverage.

Although the legality of the contract might be non-negotiable from the buyers' transactional standpoint, doctors' reports could help. Without risking their professionalism, doctors' wording could improve the chance of patients receiving their claims.

In a worst-case scenario, Choti had three simple tips for customers wanting to get their claims. From observation as a doctor, customers should increase their bargaining power. In case of the whole family being insured by one insurer, customers can threaten to terminate all their contracts wholesale, but that is not recommended, as policyholders would be at disadvantage and unable to get the full value from the deals they had made.

This being Thailand, it is also whom you know that counts. Choti said that friends in high places could help to push a claim through.

Finally, if one has neither of those options, being loud helps - perhaps become as vocal as Michael Moore.