Health Insurance Claim Denied After 8 Years of Premiums
Woman denied health insurance coverage for emergency surgery after 8 years of timely premium payments, with insurer citing a false uterine tumor history that two hospitals confirmed never occurred. Though she eventually won the claim after
On September 18, Facebook user Aum Ploynapas posted a warning to health insurance policyholders, stating she held a health insurance policy for 8 years but encountered problems claiming coverage for emergency surgery. The insurer then sent a letter reviewing coverage exclusions, citing a previous treatment history that she says is false. She urged other policyholders to examine their documents carefully.
Aum said she held a 10-million-baht comprehensive health plan and paid premiums consistently and on time for 8 full years from 2018 onwards, never missing a payment or facing any issues. Recently she was diagnosed with a blood infection caused by an emergency twisted fallopian tube that led to uterine necrosis, requiring immediate surgery to save her life. Doctors removed her right fallopian tube and uterus.
Shortly after leaving surgery, the hospital's claims department handed her documents denying the claim. The insurer claimed "coverage does not apply to conditions subject to a 120-day waiting period: uterine tumors." The insurer agreed to cover only 2 days of ICU stay but refused to cover the cost of surgery on the fallopian tube and uterus, saying if she had supporting documents she could resubmit.
However, her MRI showed no tumor. Still groggy from anesthesia as she left the operating room, she called the insurer's claims department to argue she did not have a tumor and this surgery was not tumor treatment.
The insurer then claimed that on day 81 of her first policy year in 2018, she had received treatment for a uterine tumor at Hospital A. When Aum checked with Hospital A, it issued a written confirmation stating "Medical records older than 5 years have been destroyed in accordance with law, and there is no treatment history on the dates claimed by the insurer."
When she presented this evidence to the insurer, they responded that she had "named the wrong hospital" and switched their claim to Hospital B instead. Hospital B also confirmed no history of uterine tumor treatment. When she asked the insurer to provide the treatment records they cited, the insurer "refused to send them."
Insurer Pays But Strips Future Coverage
Aum said that ultimately, with strong evidence on her side, the insurer agreed to pay the full treatment cost of over 400,000 baht because this was clearly an emergency case. But the matter did not end there. After the claim was processed, the insurer sent a "letter reviewing coverage exclusions" stating it would:
1. Impose a 120-day waiting period 2. Reserve the right "not to cover uterine tumor disease" in the future, citing the fabricated treatment history
Aum raised five points of concern:
1. Disease Mischaracterization: The pathology report after surgery clearly confirms the surgery was for "a twisted fallopian tube and necrotic right ovary." No cancer cells were found at all, yet the insurer falsely claimed it was tumor-related.
2. Policy Year Eight But 120-Day Waiting Period Applied Retroactively: The waiting period only applies to the first 120 days of the first year a contract begins. She has held the policy for 8 years (over 2,900 days), far past that period, yet they applied it retroactively.
3. No Evidence Provided: When asked to provide the treatment records they cited, the insurer refused.
4. Hospital Name Changes: The insurer switched hospitals when evidence contradicted their claim.
5. Clear Contradiction: The pathology report proves no tumor existed, contradicting the insurer's entire denial and future exclusion claim.
