WHY DID THE INSURER NOT PAY THE FULL 100%

I PAID VND 20 MILLION. WHY DID THE INSURER NOT PAY THE FULL VND 20 MILLION?

This is one of the most important things to understand about health insurance.

The amount you pay the hospital is not necessarily the amount the insurer will reimburse.

Why?

Because insurance pays according to the coverage, limits, exclusions and conditions of the insurance contract.

Example

You receive medical treatment and the total hospital bill is:

VND 20,000,000

But the policy may contain:

• Benefit limits
• Sub-limits for certain treatments
• Exclusions
• Deductibles or co-payments
• Conditions relating to waiting periods
• Other policy-specific restrictions

Therefore, the eligible amount may be lower than the total hospital bill.

Another example

Suppose your treatment costs VND 20 million.

However:

VND 15 million = eligible medical expenses

VND 3 million = expense outside the covered benefit

VND 2 million = amount subject to a policy limit or other applicable condition

The reimbursement would not simply be VND 20 million.

This is why you should check your policy BEFORE treatment.

Pay particular attention to:

1. What is covered?

2. What is excluded?

3. What are the benefit limits?

4. Are there sub-limits?

5. Is there a deductible or co-payment?

6. Are there waiting periods or other conditions?

The claims handbook itself makes clear that actual claim settlement is based on the terms and conditions of the insurance contract.

So when comparing health insurance plans, don’t look only at the annual premium.

Look at what the policy will actually pay when you need it.