What does an Integrated Shield Plan cover in Singapore

Generally, the primary purpose of an integrated shield plan is to provide reimbursement for your medical expenses. That being said, an integrated shield plan does not provide a payout for all types of medical expenses. To determine whether a medical expense is admissible, it needs to fulfil three criteria. Let’s learn about these three criteria and how to make a successful medical insurance claim.

One Minute Summary:

On the whole, an integrated shield plan provides reimbursement for medical bills relating to hospitalisation, pre- and post-hospitalisation, and selected outpatient treatments.
For a claim to be admissible, it must fulfil three criteria.
Firstly, the insurer must specify that it provides such scope of coverage. Additionally, the insurer will also specify the amount that you can claim from the integrated shield plan (eligible expense).
Secondly, you must be seeking the right medical treatment for the right medical condition (medically necessary).
Finally, the medical charges should be fair, reasonable, and aligned with the standards set by the Ministry of Health Singapore (reasonable and customary).

Part 1: What is an Integrated Shield Plan (“Main IP”)?

To begin with, let’s do a quick revision of what is an integrated shield plan. Summing up, an integrated shield plan has two components – the main integrated shield plan (“Main IP”) and the integrated shield plan rider (“IP Rider”).

The main integrated shield plan is a private health insurance scheme that provides reimbursement for hospital bills and selected outpatient treatments. Based on your health insurance needs, you may purchase a suitable IP that provides that scope of insurance coverage. For example, you may prefer to seek medical treatment at a private hospital. In this case, you may purchase an IP that provides such a scope of health insurance coverage.

Part 2: What is an Integrated Shield Plan Rider (“IP Rider”)?

Next, the integrated shield plan rider (“IP Rider”) is an optional add-on under the private health insurance scheme, integrated shield plan. At this time, the IP Rider serves two main purposes. First, to reduce the out-of-pocket cost incurred under the Main IP. In detail, the IP Rider will cover the deductible and the co-insurance component of the medical bill. Under those circumstances, your out-of-pocket cost will be limited to a smaller co-payment component. Secondly, the IP Rider provides enhanced cancer coverage for Cancer Drug Treatments and Cancer Drug Services on the MOH’s Cancer Drug List. Moreover, some IP Riders include cancer coverage for Cancer Drug Treatments that are not on the MOH’s Cancer Drug List.

In general, you will have either the Main IP only, or the Main IP together with the IP Rider. In both cases, if you wish to admit a claim under your integrated shield plan, then your medical treatment must fulfil the following three criteria (read Part 3 to Part 5).

Part 3: Eligible Expense

Firstly, the medical bill must be an eligible expense. In detail, it needs to fulfil two conditions:

Part 3.1: Scope of Coverage

At this time, the insurers have the autonomy to decide the benefits that they wish to provide for their integrated shield plans. Generally, you can find a summary of these benefits in the integrated shield plan’s Product Summary or the Product Brochure. Given that autonomy, not all the integrated shield plans provide the same scope of insurance coverage.

For example, under the integrated shield plan for private hospitals, Income Insurance is the only insurer that provides the Prosthesis Benefit. Next, AIA, Great Eastern Life, Prudential, and Raffles Health Insurance provide Congenital Abnormalities Benefit for the Insured’s biological child. If some of these benefits are important to you, then you should find out which insurer and plan provides such a benefit.

Table of Comparison (Additional Benefits Limit) for Integrated Shield Plans for Private Hospitals

Part 3.2: Limit of Compensation

In addition to the scope of coverage, the schedule of benefits also shows the limit of compensation. To explain, this is the maximum amount that the integrated shield plan will reimburse for the medical expenses. For instance, AIA HealthShield Gold Max provides the Congenital Abnormalities Benefit of the Insured’s Biological Child. In detail, you may claim up to $5,000 per child. Furthermore, there is also a lifetime limit of $20,000. Thereafter, the insurer is not liable to provide any further compensation.

Part 4: Medically Necessary

After checking through the eligible expenses, we need to ascertain whether the medical procedure is medically necessary. To answer this question, the procedure must fulfil the following seven points:

Consistent with the diagnosis and customary medical treatment, service, and/or supply for an illness or injury;
In accordance with the standards of good medical practice;
Consistent with the current standard of professional medical care, and proven medical benefits;
Not for the convenience of the insured or the physician or the specialist;
Unable to be reasonably rendered out of a hospital (if admitted for confinement), an outpatient centre, or a community hospital;
Not of an experimental, investigational or research nature, preventive or screening nature; and
Unable to be omitted without negatively affecting the diagnosed medical condition.

In summary, the insurer needs to ensure that you are seeking the right medical treatment for the right medical condition.

Part 5: Reasonable and Customary

Thirdly, the insurer needs to determine whether the incurred medical expense is reasonable and customary. That is, whether the charges are made for a procedure that is medically necessary to treat the medical condition (as mentioned in the earlier section, Part 4). Additionally, in the insurer’s opinion, the treatment must not

Exceed the usual level of charges for similar treatment, supplies or medical services in Singapore;
Include fees or charges that would not have been made if no insurance had existed;
Exceed the upper bound of the fee benchmarks recommended by the Singapore government, the Ministry of Health Singapore, or official bodies, e.g. the Health Sciences Authority; or
Exceed the insurer’s internal benchmark for episodes of care with similar diagnoses or procedures performed.

Part 6: General Exclusions

There are certain general exclusions in an integrated shield plan. For example, the insurer will not cover any pre-existing condition that you are suffering from before the insurance policy date. This is unless

You have made a declaration in the insurance application form, and
The insurer has explicitly stated that they will cover this specific pre-existing condition.

To point out, different insurers may have a different list of general exclusions. With this in mind, you should check the respective insurance policy contract to learn more.

Part 7: Last Payer Status

An integrated shield plan has a Last Payer Status clause. As its term suggests, your integrated shield plan shall be the final payer for your medical bill. To list, this is the sequence of payers:

From any other medical insurance which allows you to claim for the reimbursement of such medical expense, e.g. corporate insurance scheme, travel insurance policy;
From your integrated shield plan.

Notwithstanding that, there may be situations when your integrated shield plan issues the reimbursement first. In this case, you still need to file a claim with the other medical insurance provider. After the other medical insurance provider has approved your claim, it will reimburse your integrated shield plan’s provider.

Part 7.1: Should You seek medical reimbursement from the other medical insurance providers first?

In a word, yes. As cumbersome as it may seem to be, everyone has a role to play in managing your health insurance usage. Generally, larger medical bills and greater healthcare consumption lead to an increase in medical costs. Thereafter, excessive claims may strain the system, leading to increased insurance premiums for the integrated shield plans. With this in mind, by avoiding unnecessary claims, we can help to make insurance premiums affordable for everyone.

Part 7.2: How much reimbursement can You get?

In sum, the total reimbursement that you may receive from all the medical insurance providers shall not exceed the actual expenses incurred. To illustrate, if your medical bill is $5,000, then you will receive a reimbursement of up to $5,000. For this purpose, the payout may come from a single medical insurance provider. That being said, the payout may also be aggregated from multiple medical insurance providers, e.g. two medical insurance providers, paying $2,500 each. In any case, if you have received reimbursement from another source, then your integrated shield plan will not reimburse you for the same bill again.

Part 8: Conclusion

At this time, seven insurers offer integrated shield plans to consumers. Although each insurer can customise their plans’ benefits and costs, the three criteria help standardise the payout terms. To this end, one of their key assessments is to determine whether the medical expense arises because the condition caused harm to your body.

I must reiterate that excessive claims may lead to higher insurance premium rates for everyone. To keep the private health insurance scheme affordable and sustainable, we should use the integrated shield plan only when it is necessary. This is opposed to using it because “you have insurance coverage anyway”.

First Published: 12 February 2020
Last Updated: 24 August 2024

PZL Blog | Singapore

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