Exclusions under a medical insurance policy

Dear Mr Tan,

Some time back, I extended my Shield cover to an enhanced one. Because of my hypertension and diabetes conditions, the enhancement came with an exclusion clause to exclude these two conditions and their sequelae. I understood "sequelae" to mean conditions resulting from, or a consequence of, hytension and diabetes.

I would like to know from your experience that when invoking this exclusion clause, whether the onus should be on the insurance company to provide medical certification to prove cause and effect, ie that hypertension and/or diabetes result in or caused another condition for which an insurance claim is being made under the enhanced policy.

Hypertension and diabetes are generally recognised as risk factors for numerous diseases affecting the heart, kidney, liver etc, But it does not mean the these diseases are automatically a sequelae of hypertension or diabetes as there are also other causes.

If such exclusions are meant to have a blanket cover on such common and widespread disease without evidence of connectivity, then you can imagine how "useless" it is to pay to get insured in a nation-wide medical insurance scheme which is meant to be our main protection in the absence of any public-funded scheme. I hope you can illuminate.

REPLY
I suggest that you ask the insurance company to give their explanation on this matter. You can send it to me after getting that explanation. I shall see if it is a reasonable interpretation.

I believe that the onus of proof is on the insurance company, if they wish to reject a claim due to the exclusion clause.

It is important for an insurance company to provide contractual terms that are clear to the consumer.