Recently, the country's celebrity world has been buzzing with news about a
public figure, actress, and former member of parliament who has expressed
her disappointment with an insurance company on her social media account.
He admitted that he was disappointed because he felt he had been a loyal
customer for so many years, but he could not get the appropriate coverage
benefits when one of his children had to undergo surgery for an injury to
his leg.
What's interesting is that, in the comment column which contains mutual
disputes, pros and cons in the post, there is a comment from an account that
provides a little explanation regarding the inappropriateness of the
insurance benefits received by the politician's child.
After trying to reconstruct the chronology of the story that was built in
the account on social media earlier, the account owner in the comment column
concluded that what the customer experienced was the occurrence of a
pre-existing condition clause in insurance, which could indeed lead to the
cancellation of the agreement and claims from the insurance company.
Then what exactly is the pre-existing condition clause in insurance, and why
can it lead to the cancellation of the customer's claim? Insurance observer
Kapler Marpaung said, a pre-existing condition is a health condition that
existed before the insurance policy took effect.
“Usually, this pre-existing condition is an exception to the protection
provided. For example, if a customer already has a congenital heart disease
that he suffered before buying an insurance policy.
Then when submitting an Application for Life Insurance or Health Insurance,
the congenital disease is not conveyed to the insurance company. So if after
the policy is valid and he submits a claim for his heart disease, the claim
can be canceled by the insurance company, "explained Kapler in his
statement, Wednesday (13/10).
According to the man who also serves as Chairman of the Wealth Management
Standard Board Indonesia (WMSBI), in fact the cancellation of claims due to
the imposition of a pre-existing condition clause can be avoided by
providing information regarding the health and medical history of the
prospective customer in an open and transparent manner. According to Kapler,
when a customer decides to buy a health insurance policy, for example, he
should state all the medical data he has in his application for insurance
protection.
"So that the insurance company can determine or decide whether the insurance
company will accept the application, or whether the company will accept it
with a number of conditions, or the insurance company will refuse," he
added.
So that if a claim occurs later, there will be no problems regarding its
legality. So the prospective customer must provide all his medical history.
Openness must be done," he continued.
Kapler also said that certain insurance companies may set policies so that
the customer can still get the protection program provided. For example, if
the customer turns out to have medical traces of certain serious illnesses,
the insurance company may prepare a contract with a clause that the claim
benefit can only be received by the customer after a certain period of time
has passed after the policy has been issued.
“There are insurance companies that want to guarantee certain risks that
have occurred before the policy applies. It's just that claims can only be
served after two years of the policy being valid, for example. Or there are
also those that apply after three years of the current policy. It depends on
the type of critical illness,” said this member of the Advisory Board of the
Indonesian Insurance and Reinsurance Brokers Association (ABAI).
However, according to Kapler, this clause that can lead to a win-win
solution for customers and insurance companies can only be realized if
information disclosure has been implemented from the beginning from
customers to insurance companies.
"This is a kind of goodwill from the company in providing insurance
protection to the public," he said.
Kapler also said, on the other hand the insurance industry must be able to
provide very detailed education to prospective customers, in order to avoid
mis-selling.
Next, Kapler also urges customers to read each clause of the insurance
agreement carefully, so that they can file objections or make corrections if
there are articles that are considered unfavorable.
“What the public as potential customers don't really understand is that they
actually have a free look period, or free look provision. This means that
prospective policyholders have time to first examine their policies, or
study them again, to make a final decision," he explained.
Generally, this free look provision period lasts 14 days from the time the
prospective customer receives the policy, and all life and health insurance
products apply this clause as a goodwill gesture from the insurance company,
so that there is no prejudice that insurance companies are only pursuing
policy sales targets.
“So, before buying a policy, understand the product you want. Read carefully
the articles of agreement in the policy, and provide all personal
information transparently and honestly. The selling agent does not know the
actual condition of the prospective customer, only the prospective customer
personally knows," said Kapler.
