Hospitalization – Exclusion

Background

The assured’s Hospital and Surgical claim for his admissions on 13/9/2016-14/9/2016 in Penang and 3/10/2016-4/10/2016 in Singapore for “No Recurrent Brain AVM” was repudiated on the ground that both his admissions falls under the policy exclusions (3 policies).

 

The Insurer had referred to the policy provisions stated under the 3 policies involved:

“Policy 1

10.1. EXCLUSIONS

(m)This Supplementary Insurance does not cover routine medical or physical examinations, outpatient physical therapy, investigative procedures or tests not incidental to the treatment or diagnosis of a covered condition or treatment not medically necessary.

 

Policy 2

4.1 EXCLUSIONS

(m) This Annexure does not cover routine medical or physical examinations, investigative procedures or test not incidental to the treatment or diagnosis of a covered condition or treatment not medically necessary.

 

Policy 3

5.1 EXCLUSIONS

(i) This contract does not cover Hospitalisation primarily for investigatory purposes, diagnosis, X-ray examination, general physical or medical examinations, not incidental to the treatment or diagnosis of a covered Disability or any treatment which is not Medically Necessary and any preventive treatments, preventive medicines or examinations carried out by a Physician, and treatments specifically for weight reduction or gain.”

 

Investigation and Findings

The Case Manager observed that the Insurer’s decision was based on the following Medical Attendant’s Report duly completed by:

(i)Dr.X from Penang wherein it was reported that the assured was diagnosed with “Left occipital arterio-venous malformation” and Cerebral Angiogram with digital subtraction were done; and

(ii)Dr.Y from Singapore wherein it was reported that the assured was diagnosed with “No Recurrent Brain AVM” and Angiogram for Gamma knife were done.

 

The Insurer contended that both the assured’s admissions were solely for investigation purpose and there were no treatment rendered.

The Case Manager highlighted that all the above exclusions had clearly stated that the policy will not cover investigative procedures which are NOT incidental to the treatment or diagnosis of a covered condition only. In the present case, the investigative procedures done were MRI Brain and Cerebral Angiogram which was directly related to assured’s diagnosis of “Brain AVM”. As such, the Case Manager was of the view that the above exclusion is not applicable.

It was further observed that the MRI Brain and angiogram procedure done at Singapore was initially scheduled with the intention of having Gammaknife radiosurgical treatment and not merely for investigation purpose.

This treatment was scheduled due to two MRI Brain and four vessel angiogram (all done in Penang) findings which continuously showed presence of AVM nidus. However, on the treatment day, as the catherer angiogram did not show any AVM nidus, Dr.Y decided to cancel the Gammaknife radiosurgical treatment as it is not needed anymore.

The Case Manager also stressed that the assured should not be penalized as it was not the assured’s decision to undergo the Cerebral angiogram in Penang and also get admitted in Singapore and undergo the angiogram and Gammaknife radiosurgical treatment. The attending doctor, Dr.X, based on his expertise has advised the assured for these procedures as it is deemed absolutely necessary in these symptomatic patients.  As a layman, he had just followed the attending doctor’s advice and he proceeded with the angiogram in Penang and treatment at Singapore.

The Case Manager also brought the Insurer’s attention to their policy provision which states:

 

Medically Necessary” means a medical service which is:

a) consistent with the diagnosis and customary medical treatment for a covered Disability; and

b) in accordance with standards of good medical practice, consistent with current standard of professional medical care, and proven medical benefits, and;

c) not for the convenience of the Life Assured or the Physician, and unable to be reasonably rendered out of hospital (if admitted as an Inpatient), and ;

d) not of an experimental, investigational or research nature, preventive or screening nature, and ;

e) for which the changes are fair, reasonable and customary for the Disability.

 

The Case Manager opined that the admission on 13/9/2016 in Penang (to confirm the presence of AVM before referring to Singapore) and his admission on 3/10/2016 in Singapore (which was meant for Gammaknife radiosurgical treatment for his diagnosed AVM nidus) were medically necessary and consistent with the diagnosis and customary medical treatment for a covered Disability.

 

Settlement

The Insurer reviewed the case and agreed to settle both the hospitalization claims.