F.A.Q

The claim will be reimbursed by the company within 10 working days after receipt of the complete documentation supporting the claimed amount. The original receipt (not photocopy) documentation is required to support your claim.

All documentation in support of a claim can be submitted in either Thai or English language. Where documentation is provided in a language other than Thai or English a certified and approved translated copy of the relevant document must be submitted in support of your claim.

If the company is required to translate the supporting documentation for a claim, the cost of the translations will be deducted from the claimable amount.

The entire amount of the claim is payable, provided it complies with policy conditions and benefits payable. Your claim must be supported by the proper claim documentation, except for the expenses which are excluded under the policy that you have purchased.

This means you can walk into any of our network hospitals and clinics throughout Thailand, Laos and Cambodia (approx. 340 in number) and get treated without having to pay your bill first, then your claim from the company is subject to the benefit levels and policy terms and conditions that apply.

If you do not get treated at a network hospital or clinic, your expenses will be reimbursed on receipt of complete documents from you. In this instance you must “pay first, then claim back” the claim costs incurred.

Here in Thailand and for that matter in other countries, the cost of healthcare is growing at an alarming rate and many people simply do not have the financial resources to meet the costs of a serious claim for healthcare such as – Cancers, Heart Attacks, Strokes, etc., which run into the millions of baht. Health insurers provide that “financial” peace of mind when a policy is purchased, of course the benefit levels chosen do impact on the level of financial support that is secured.

For most expatriates in the past there was often the option to return to their home country for treatment in the event of serious illness. However, many governments have made alterations to their legislation which means that this option may no longer be available.

In addition, in some countries international health insurance allows you to gain access to the top hospitals in a foreign country and avoid the local hospital network. It may also allow you to be repatriated to your home country to receive treatment and to be near family or friends. It should also cover accidents, which you can never predict.

Health insurance is a must for peace of mind.

This is a percentage of your medical costs that it is your responsibility to meet. The purpose of this is to contain spiraling insurance premiums and allow a policy holder to determine if hospital treatment is really required or can a visit to a local pharmacy provide adequate relief to the illness. Premiums charged reflect co-payment conditions that have been applied. For the deductible this is the annual level of healthcare costs that you absorb before claiming under you insurance policy.

When you present your medical card to a network hospital or clinic for the payment of your claim, the hospital staff will ask you to pay the co-payment contribution to the eligible expenses approved by the insurance company.

There are no hospital restrictions; you are free to use any one of your choosing. Pacific Cross Health Insurance PCL have a network of over 340 hospitals throughout Thailand, Laos and Cambodia and when you present your medical card at any one of these hospitals, they will bill us directly for the medical expenses for which we are responsible. A list of the Hospital Network Members is available in your policy handbook for your reference. However, if you have any queries please feel free to contact Pacific Cross Health Insurance PCL on 02 401 9189 and we will be happy to clarify matters for you.

If you have already been prescribed certain medicines that you need to take on an ongoing basis to control High Blood Pressure or Hypertension, for example, the doctor will have already provided the insurance company with a copy of your Medical Certificate. This allows the insurer to understand that certain medicines have been prescribed, the type, quantity and frequency of treatment. In this case you can simply go to a local pharmacy and buy the medicines you require.

This also applies to one-off prescriptions. You can also take a doctor’s prescription to the pharmacy to obtain your drugs. To reimburse these costs from the insurer you will need the original doctor’s prescription, medical certificate and an original receipt from the pharmacist.

You can visit any registered local pharmacy for the purchase of your required ongoing medicines (e.g. Hypertension, Cholesterol medicines, etc) as identified on your Medical Certificate. That registered pharmacy needs to provide you with a receipt which bears their company’s name, address and Tax Number including the full name and registration number of the prescribing pharmacist. The original documents are required for reimbursement purposes. Such visits are treated as an out-patient visit under your insurance policy.

The treatment of pre-existing conditions is not covered under our policy, unless specifically agreed to prior to the commencement of the policy. A pre-existing condition means any medical condition (including conditions that are a consequence of the said condition), which presents signs or symptoms in a period of 5 years prior to the first policy effective date that would cause a reasonable person to seek diagnosis, care or treatment, or for which diagnosis, care or treatment was given before the policy effective date.

No, congenital conditions are an exclusion under the policy. A “congenital condition” is “a physical or mental abnormality existing at the time of birth or manifesting itself within six (6) months from the date of birth”. It is a condition of physiological or structural abnormality that develops at or before birth and is present at the time of birth. These include, but are not limited to:

◦ Down’s Syndrome

◦ Cleft lip/palate

◦ Hearing impairment

Our plans offer worldwide emergency coverage; however, they do NOT cover “elective treatment” in the under mentioned countries, unless this benefit is agreed to prior to the commencement of the policy and this benefit is specifically stipulated in your plan.

▪ North America

▪ Japan

▪ Hong Kong

▪ EU Countries

▪ Switzerland

However, you are still covered for accident and emergency treatment in all countries worldwide 7 days per week 24 hours per day.

It means that you can elect to receive major intervention medical treatment in the country of your choice within the geographical area that your policy covers. This is subject to the terms and conditions of your policy document and our physician’s agreement and advice. The policy benefit levels are expressed in Thai Baht and the cost of treatment may exceed your benefit levels. In such instances, the insured member must meet those costs.

No. Routine medical check-ups and vaccinations are not covered, this includes suggested exploratory procedures by medical professionals.

Yes, the amount is identified on your policy Benefit Schedule, Medical Card and includes bed, food and nursing services. Each policy type has a limit identified as the maximum payable by your insurer for this particular benefit. We recommend that you check with your hospital as to exact benefits that their specified “room rate” covers e.g. room, food, etc. Excesses are met by the insured.

A private room, however, please note that the cost is limited to the daily rate specified on your policy Benefit Schedule or Medical Card, which is inclusive of bed, food and nursing services.

Yes, but only where the policy that you have purchased specifically covers this activity. You are allowed one out-patient visits per day up to a maximum of 30 visits per year. Please note that visitations to drug stores and pharmacies (outside of the hospital) for the procurements of medicines are considered as out-patient visits under the policy, assuming that you have this provision under your policy.

You must contact us in advance for pre-authorization if you require hospitalization. In such instances the hospital will provide us with details of the required treatment costs. The estimated cost of treatment is required to allow the insurance company to determine if such costs are considered “normal and customary”. The insurer will then issue the approval conditions. Excessive costs will not be accepted by the insurer.

By accepting an annual deductible on the plan, being prepared to have a co-payment arrangement for your medical costs, exclude outpatient benefits. When making claims under the policy, check your hospital expenses (in-patient or out-patient) to ensure they are correct – e.g. quantity of medications received. Ask yourself the question -Is this correct?

Yes, this is your legal right. Take the time to read what has been written regarding your health status.

You or someone designated by you must contact us as soon as you are able to do so.

The consulting doctor must identify the treatment required and also provide the name of the specialist who will undertake the procedure. This information must be submitted to the insurance company for acceptance and approval. Thereafter you can visit the specialist.

In the event that local medical facilities are deemed by our physicians to be unable to cope with your condition, you or your treating physician need to contact our 24 Hour Emergency Assistance Centre immediately. Your condition can then be assessed with the necessary arrangements made for you to be transported or evacuated to the nearest facility considered acceptable to undertake the required treatment.

A chronic condition is a medical condition that is of more than 6 week’s duration. These include:

▪ Heart Disease

▪ Diabetes

▪ Hypertension

▪ Hyperlipidemia

▪ Arthritis

▪ An illness that recurs or is likely to recur

▪ An illness that requires monitoring, consultations, check-ups, examinations or tests

Note: This list is only intended to provide a guide to the interpretation of a chronic condition.

You complete an application for your child and submit it to the insurer for Underwriting. Acceptance terms will be then be provided to you. Upon acceptance your child will receive free “inpatient” coverage from the date of acceptance until the next renewal date of your policy. Please note that there is no coverage for out-patient treatment and “Wellness Checks” and “Vaccinations”.

Where there is no maternity benefit applying to your policy the “free cover” for new born children continues to apply (Group Plans excluded). Age Band premiums for children of all ages will apply at the policy renewal date. This does not prevent a parent for applying for coverage of the child under their policy plan or as a standalone policy, however for new born children of less than 15 days no cover is available.

The application for the child can be completed by either parent.

In case you are hospitalized with an eligible illness or disease and you are a member of the SSF, you can select to use the SSF benefit first. The excess of eligible expenses covered by SSF will be fully covered by your Pacific Cross Health Insurance PCL policy up to the limits specified on your membership card.

The prescribed medicines are covered even if they were purchased from different drug stores or pharmacies. However, the dosage purchased must be in line with the amount prescribed on the Medical Certificate. The original receipt with drug store or pharmacy stamp is required for reimbursement. We can then match this with the Medical Certificate that we have on file for reimbursement purposes. Such visits are treated as an out-patient visit under the insurance policy.

When emergency medical expenses are incurred outside of Thailand, all medical claims are subject to us on a reimbursement basis. Please submit the original receipt for the doctor’s consultation, any medical supplies, the medical certificate, and treatment report as provided by the attending physician for claim consideration. However, in the event that the medical costs are likely to exceed THB 100,000 you can contact the Pacific Cross Health Insurance PCL Office or our international emergency services provider (contact phone numbers are on the reverse side of your Medical Card) for further assistance. If the treatment you require is covered, we will arrange to pay all eligible medical expenses directly to the medical facility you are attending.

The Major Medical Benefit will cover the excess of eligible expenses under your basic in-patient plan. Should a co-payment condition apply to your policy the amount of your co-payment will be applied to your eligible medical expenses.

Yes. To make a claim under your policy you must provide the receipt from the registered pharmacy which includes their address, tax number and the name and registration number of the attending pharmacist including the name and full details of the prescribed medicines purchased, including quantity.

A medical charge is “normal and customary” when it is the same or similar amount for the same or similar service in the same or similar geographic area by the same or similar medical providers. If 100 surgeons charge between 40,000 and 60,000 baht for the same surgery in the same area then the range of normal and customary charges is 40,000 to 60,000 baht and the average is 50,000 Baht.

If what the surgeon charges you (or your doctor) is higher than what we consider ‘normal and customary’ for the covered service, then we may not allow the full amount to be claimed.

Yes, however in some cases these are only permitted after an elapsed time period. You must first check your policy conditions in this regard.

There is no question that health insurance is becoming less and less affordable as the cost of healthcare continues to escalate. For families living overseas the costs can be significant if health insurance is not provided as part of their remuneration package.

However, the impact of health insurance costs can be reduced by finding a provider that will allow you to spread the cost of payments throughout the year, or who offer an optional deductible or excess on the plan that you have chosen. In addition, opting to take a reasonable deductible/excess can often reduce your annual premium by 20% or more. Choosing the right health insurance policy for what you need and getting the right advice through a healthcare insurance broker could also reduce the premium costs.

As you would expect health insurance starts to get expensive as we reach the twilight years. Health insurance does get more expensive for senior lives e.g. over 60’s. Again, getting the right advice on policies that cover you up to a certain age or seeing large increases in premium due to your age (although you might be extremely healthy) is also important. Premium costs can be controlled to a degree through the selective use of a deductible or co-payment under your policy.

Insurance is really for what you cannot afford to pay for!

Coverage for dental, routine health checks, routine visits to the doctor for common ailments all add significantly to the premium. And frankly, these are still relatively affordable in Thailand. However, make sure any plan you choose covers fully any treatment that is serious enough to require a stay in hospital or prolonged treatment on a day-care basis.

People have a choice of course. For long-term expatriates there are benefits associated with purchasing a policy locally. Locally licensed health policies are tax deductible for businesses and do not count as a benefit-in-kind for the employee. More importantly, if there is a dispute with an insurer (in Thailand) then you can seek recourse through the OIC (Office of Insurance Commission) who protects the consumer by ensuring that the insurer follows the requirements of their policy and the law.

Buying an off-shore product does not offer such protection – the old adage of “buyer beware” applies.

Company Group Scheme Members often assume that because they have health insurance provided by their employer then they are covered for all eventualities. However, the truth is that unless the overall annual benefit per medical condition limit of the policy is at least 5 million Baht, then you are under-insured.

If the cover offered by an employer really isn’t sufficient, it is worth using what cover there is for routine medical treatment and as the deductible/excess amount for a more comprehensive medical insurance plan. In addition to this it allows you to get accepted by a medical insurer before your membership in your company’s Group Medical Plan terminates. By using the benefit level of your company scheme as the deductible for your own policy, premium discounts of up to 50% can be achieve for a more comprehensive medical insurance plan.

It is important to note that memberships of Group or Employer Medical Plans terminate at age 65 years.

It is difficult to comment without being in possession of all the facts. From experience most health/medical questionnaires seek out treatment of medical conditions, not what preventative medications or measures are being taken. With this knowledge insurers can then underwrite the medical conditions that an applicant suffers from. The real issue identified in the question is the consequences of such a condition. In this instance our company will not pay for the investigation and treatment of such a condition but will pay for the consequences e.g. Stokes, Heart Attacks. Other companies do not as they exclude the consequences of the medical condition.

Generally insurers will not cover pre-existing conditions. Other than this, medical insurance plans can cover most eventualities which are medically necessary; however, this can be costly. People should study the policy documents carefully before making a commitment. Or better still, consult an independent insurance broker that specializes in health insurance to weigh up all the options available to them in Thailand.

Yes, Pacific Cross Health Insurance PCL policies are guaranteed for life.

If you were to seek to change insurers after a large claim, you are morally obligated to advise the new insurer the details of your previous insurer and your claim. They in turn would seek information regarding your prior claims history and apply a premium rate commensurate with the health risk that you present. However in saying this, insurers generally vary in their attitude towards someone who has high claims and a careful check would be made before offering coverage by that replacement insurer. In some instances you may be declined cover.

This is difficult to predict, but health inflation has been running at anywhere between 9% and 14% per annum in recent years. This is due in part to the increasing costs being charged by hospitals and also to the advances being made in medical treatment and technology. Again, getting the right advice is crucial if looking at sustainable pricing year on year.

Generally, most “international” styled policies cover evacuation and/or repatriation to Thailand if medically necessary, but do check this aspect of your policy.
Health insurance will not cover loss of earnings. Other insurances are available to compensate for loss of earnings in the event of serious accident/illness.
Not all policies provide Personal Accident cover so you must check out this aspect of the policy that you purchase. Our company provides a built in level of Personal Accident cover.

Pre-existing conditions
Treatment relating to alcohol or drug abuse
Self-inflicted injuries
Cosmetic surgery
Dietary supplements
Treatment for addictive or compulsive disorders
Sexually Transmitted Diseases (STD’s)
HIV/AIDS
This is by no means an exhaustive list. In addition, insurers will generally not cover pre-existing conditions but terms and conditions do vary from insurer to insurer so it does pay to check carefully. Take the example where a person is taking medication for high blood pressure. One insurer may exclude treatment for this and all related conditions, including heart attack and stroke. On the other hand, if the medication maintains that person’s blood pressure within acceptable limits, another insurer may exclude the routine treatment of high blood pressure but provide coverage in the event of a heart attack or stroke. It does pay to check.

The other area that insurers tend to put caps on things, if they offer cover at all, is the routine treatment of chronic conditions because treatment costs can be high and continue for many years. Common chronic conditions include the following:

Arthritis
Asthma
Diabetes
Epilepsy
Heart disease