Raffles Health Insurance Claim Denied in Singapore: How to Appeal

Raffles Health Insurance Claim Denied in Singapore: How to Appeal

Raffles Health Insurance is the insurance arm of the Raffles Medical Group — one of Singapore's largest private healthcare organisations. Raffles Health Insurance provides Integrated Shield Plans (Raffles Shield), health insurance products, and supplementary insurance plans tailored to the Singapore market.

The unique aspect of Raffles Health Insurance is its tight integration with the Raffles Medical Group healthcare network — making pre-authorisation, referrals, and claim processing closely tied to the Raffles ecosystem. When a claim is denied, policyholders have rights to challenge the decision through Raffles Health Insurance's formal complaints process and through FIDREC (Financial Industry Disputes Resolution Centre).

About Raffles Health Insurance

Raffles Health Insurance's key products include:

• Raffles Shield — Integrated Shield Plan (Ward A, B1, and private hospital tiers)
• Raffles Shield rider — covers deductibles and co-insurance
• Raffles Health Insurance (RHI) plans — additional health protection
• Group health insurance for corporate clients

Raffles Shield operates in conjunction with MediShield Life, with Raffles Health Insurance paying above the MediShield Life layer. Claims are closely tied to the use of panel/preferred hospitals and specialists.

Common Raffles Health Insurance Denial Reasons

Raffles Shield hospitalisation claims:

• Pre-authorisation not obtained: For non-emergency admissions, Raffles Health Insurance requires prior authorisation. Failure to obtain it can lead to a denied or reduced claim.
• Non-panel specialist or hospital: If you are admitted to a hospital or treated by a specialist outside Raffles Health Insurance's panel, coverage may be reduced or denied depending on your plan.
• Ward class above plan entitlement: Raffles Shield plans are tiered (Ward B1, Ward A, private hospital). Being admitted to a higher ward class than your plan covers results in Raffles paying only at the lower rate.
• Treatment not medically necessary: Raffles Health Insurance may determine a procedure was elective or not medically necessary.
• Excluded conditions: Congenital conditions, cosmetic procedures, self-inflicted injuries, and certain psychiatric conditions are excluded.

Outpatient claim disputes:

• Outpatient coverage varies significantly by plan. Some Raffles Shield plans do not cover outpatient consultations. Disputes arise about whether outpatient expenses are covered.

Critical illness or life insurance (if bundled):

• Policy definition not met for the claimed condition
• Non-disclosure of pre-existing conditions at application

Pre-existing condition exclusions:

• Conditions existing before the policy's commencement date are typically excluded under standard terms
• Moratorium-based exclusions (if applicable to your plan)

Your Singapore Rights When Raffles Denies a Claim

MAS regulation: Raffles Health Insurance Pte. Ltd. is regulated by the Monetary Authority of Singapore (MAS).

FIDREC: For unresolved disputes, you can file with FIDREC for independent adjudication binding on Raffles Health Insurance (within FIDREC's jurisdictional limits).

LIA Singapore: For life insurance components, the LIA Claims Conciliation Panel is available.

Step-by-Step: How to Appeal a Raffles Health Insurance Denial

Step 1: Review the Denial Notice

Raffles Health Insurance must provide a written explanation of the denial, citing:

• The policy clause or exclusion being applied
• The factual reason for the denial
• Your right to complain

Step 2: Access Your Policy and Review the Coverage Terms

Log into the Raffles Health Insurance member portal or request your full policy document. Review:

• The specific coverage terms for your plan tier (Ward B1, Ward A, private)
• The definitions and exclusions
• The claims conditions and pre-authorisation requirements

Step 3: Gather Supporting Evidence

For hospital claims:

• Hospital discharge summary and itemised bill
• Treating specialist's letter confirming medical necessity
• Pre-authorisation approval confirmation (or documentation of emergency circumstances)
• Referral letters from treating doctors

For outpatient disputes:

• Doctor's referral letter and medical reports
• Evidence that the outpatient treatment is linked to a covered inpatient condition (if applicable under your plan)

For pre-existing condition disputes:

• GP records showing timeline of symptoms and diagnoses
• Letter from GP confirming what was known at the time of policy application

Step 4: File a Formal Complaint with Raffles Health Insurance

Raffles Health Insurance Customer Service:

• Phone: 6311 2888
• Online: raffleshealthinsurance.com.sg/contact
• Email: customerservice@raffleshealthinsurance.com.sg
• Post: Raffles Health Insurance Pte. Ltd., 585 North Bridge Road, Raffles Hospital, Singapore 188770

State clearly that this is a formal complaint against the claim denial. Include:

• Policy number and claim reference number
• Written appeal letter explaining why the denial is incorrect
• All supporting documentation

Step 5: Leverage the Raffles Medical Group Connection

Since Raffles Health Insurance is affiliated with Raffles Medical Group:

• Your Raffles Medical Group specialist or the Raffles Hospital patient relations team may be able to liaise directly with Raffles Health Insurance on your behalf
• Ask your treating specialist to write directly to Raffles Health Insurance's clinical team explaining the medical necessity

This integration can sometimes resolve claims disputes more quickly than at arm's-length insurers.

Step 6: Escalate to FIDREC

If Raffles Health Insurance's response is not satisfactory:

• File a complaint with FIDREC (fidrec.com.sg)
• Filing fee: S$50 (refundable if successful)
• Deadline: Within 6 months of Raffles Health Insurance's final response

FIDREC provides independent adjudication binding on Raffles Health Insurance.

Step 7: Singapore Courts

For claims outside FIDREC's jurisdiction or where you reject FIDREC's outcome, civil action in Singapore's courts (including the Small Claims Tribunals for smaller amounts) is available.

Raffles Health Insurance-Specific Tips

Raffles ecosystem advantage: If you receive treatment within the Raffles Medical Group network (Raffles Hospital, Raffles Medical clinics), the administrative coordination between the hospital and Raffles Health Insurance is typically smoother. Keep all treatment within the network where possible.

Pre-authorisation for surgery: Always call Raffles Health Insurance's pre-authorisation hotline before any elective surgery. Obtain a written approval reference number.

Panel specialist list: Verify that your treating specialist is on Raffles Health Insurance's panel before booking. Panel specialists accept Raffles Health Insurance's fee schedules directly, reducing your out-of-pocket exposure.

ISP deductible and co-insurance: Even with a Raffles Shield rider, you may have residual deductibles or co-insurance obligations. Review your plan terms to understand what you are responsible for vs. what Raffles Health Insurance covers.

Annual limits: Raffles Shield plans have annual benefit limits. If you have had multiple hospitalisations or expensive procedures in a policy year, verify that your current claim falls within the remaining annual limit.

Conclusion

Raffles Health Insurance's integration with Raffles Medical Group provides some unique advantages in resolving claim disputes — but when disputes occur, the standard Singapore insurance regulatory framework applies. File a formal complaint, gather strong medical evidence from your Raffles Medical Group specialists, and escalate to FIDREC if needed. Use ClaimBack at claimback.app to generate a professional appeal letter for your Raffles Health Insurance dispute in Singapore.

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