When deciding to file an insurance claim for his bedridden wife, the family was surprised to discover that the insurance agent had been holding onto the documents for 5 years and had not submitted them to the company.
The customer was taken by his family to undergo a health check-up, after many years of suffering from a stroke and paralysis - Photo: BONG MAI
Not receiving insurance compensation when his wife was paralyzed and bedridden, after being guided by a specialist, the customer's family decided to go through the insurance claim procedure for his wife and were surprised to discover that the insurance agent had been holding onto the documents for 5 years and had not submitted them to the company.
It is worth mentioning that during the 5 years that the customer is bedridden, the customer's family still has to pay the normal insurance premium.
When the insurance claim was reviewed, the insurance company refused to refund the premium that the customer's family had paid for the past 5 years.
Agent holds files for 5 years, does not submit to insurance company
Early in the morning, jostling among the crowded crowd at Nguyen Trai Hospital (District 5, Ho Chi Minh City), Mr. Hong held a stack of medical records, his wife was pushed by her daughter-in-law in a wheelchair beside him, to ask for the procedure to assess the disability rate.
Sharing with us when his wife went inside the room to see the doctor for support, Mr. Hong said that his wife had a stroke 5 years ago. She was paralyzed on the left side of her body, bedridden, had memory loss, crooked mouth, not to mention high blood sugar.
At that time, the family reported the patient’s illness to an insurance agent named Hoang Anh. This person came to visit and took all the patient’s medical records home. After a while, the insurance agent informed that the patient had suffered a stroke and would not be covered by insurance.
After many years of suffering, with the guidance of a professional, Mr. Hong recently decided to go through the procedure to claim compensation for his wife. At this time, Mr. Hong was shocked to learn that the agency had been holding onto the documents for 5 years without submitting them to the company.
According to data collected by the reporter, in a conversation with the insurance agent, Mr. Hong questioned that when his wife first got sick, he had collected her medical records and given them to her, but why the agent did not submit them to the insurance company.
The agent explained: "Because I sent it, but yours didn't cover critical illness (...), so we didn't submit it. That means we only bought "Lifetime peace of mind"." The conversation ended because the agent said he was out and would call later.
In another conversation, he and his daughter also asked why the customer's medical records were not "pushed" back to the company. The agent gave many reasons as researched and "asked above", because the customer did not buy the secondary product - health care insurance.
"It demands back and forth, medical examination and all sorts of things," the insurance agent said and then affirmed, "If I could do it, I would do it for you. It's the company's money." The insurance salesman added, "There have been so many cases here."
Customers have difficulty claiming insurance
According to the insurance seller, "as long as there is a risk and the money is not received", he will be responsible, then gave an example of a case where a customer died and his family received the insurance compensation quickly. "We have lived together since then" - the insurance seller affirmed the relationship, asking Mr. Hong and his family to trust him.
"The insurance seller and his wife are friends, not knowledgeable, and weak in the profession. I had to accept what the seller said, but I felt very resentful inside. Being sick and bedridden, not only did I not get compensation but I also had to pay insurance premiums all the time, how could I bear it, I was so angry!", Mr. Hong was indignant.
After many years of treatment, luck came in early 2024 when the wife gradually recovered, her face was somewhat more awake. But she was still weak, had to use a wheelchair, had to wear diapers to urinate, and often forgot her loved ones.
After Tuoi Tre newspaper reported the incident, Prudential Insurance Company issued a referral letter for Mr. Hong to take his wife for a medical examination. By the end of November 2024, 5 years after the incident, the medical examination agency determined that the customer suffered a physical injury of 82%, meeting the conditions for receiving permanent total disability benefits.
Responding to Tuoi Tre newspaper in mid-December 2024, Prudential said that based on the results of the medical examination, the company agreed to pay the customer permanent total disability benefit (VND 100 million).
In a recent conversation, the insurance agent said she considered Mr. Hong's wife as her "real sister", "as close as blood".
This person admitted: "My mistake was not submitting the medical records, I was wrong, I accept my mistake". The insurance agent expressed his wish to quickly resolve the matter smoothly, "clear it" so that he could celebrate Tet, if the electricity company kept calling back and forth, it would be difficult to do business.
Regarding the complaint that the insurance agent received documents 5 years ago but did not submit them to the company, affecting the customer's rights, in response to Tuoi Tre newspaper, Prudential said: "The company has received the complaint, the professional departments are coordinating to resolve it, with the motto of putting the customer at the center and in the spirit of complying with the provisions of the law."
Mr. Hong went through the procedures to claim insurance benefits for his wife who suffered a stroke and was paralyzed for many years - Photo: BONG MAI
The company is responsible when the agent makes a mistake.
Pursuant to Article 128 of the Law on Insurance Business 2022, in case an agent breaches the contract, causing damage to the legitimate rights and interests of the customer, the insurance company must still be responsible for performing the obligations as agreed in the insurance contract arranged by the agent.
According to Article 129, the agent is responsible for reimbursing the insurance company for the amounts that the company has compensated customers due to the agent's violations.
Long-term paralysis, insurance company demands more evidence
After 5 years of the incident, Prudential has just officially decided to pay insurance benefits of 100 million VND to Mr. Hong's wife (HCMC).
However, the customer also requested that the company return 50 million VND in insurance premiums paid over the past 5 years along with interest accrued on this payment because the customer had a stroke since mid-2019.
Regarding this refund issue, Prudential said that during the discussion, the customer and his family stated that the customer had been severely paralyzed (bedridden) since 2019.
But up to now, in addition to the appraisal results (with the above payment decision), Prudential has only received a summary of the medical record extracted on June 7, 2019, which does not describe the customer's injury status upon discharge from the hospital: the level of paralysis, or the rate of disability.
Therefore, the company will notify about the review of the file/request, after the customer submits more detailed medical records of Thong Nhat Hospital in 2019. On the other hand, the company "will also make efforts to collect more detailed information on the customer's medical records about the injury for further assessment to ensure the customer's legitimate rights in accordance with the principles of insurance benefit payment".
Based on the medical record summary (June 7, 2019) that the reporter received, in the summary section of the disease process and clinical developments, the hospital stated: 64-year-old female patient, admitted to the hospital due to sudden hemiplegia with difficulty speaking, left hemiplegia, crooked mouth, and high blood sugar fluctuations.
Summary of diagnostic paraclinical test results: right ventricular infarction, occlusion of anterior cerebral artery (right) segment A2. Treatment direction: re-examination when finished medication, physical therapy.
Agent wants to refund premiums out of pocket
In a recent conversation, the customer's daughter questioned whether it was because the agent told the company that her mother was in good health that the company did not refund the fee (50 million VND, paid since the stroke and paralysis of half her body, not including interest).
The son emphasized that his mother had been paralyzed for several years, and after a long period of treatment, "she is now a little better." The insurance agent explained that the reason the company had not refunded the insurance premiums paid for the past five years was due to the terms of the contract, not because of what she said.
In December 2024, the insurance agent expressed their desire to be compensated, meaning they would use their own money to pay back 50 million VND. But Mr. Hong's family did not want to receive outside money, they only wanted to go the official way, that is, receive money from the company.
Source: https://tuoitre.vn/ngan-chay-i-boi-thuong-bao-hiem-ky-3-dai-ly-ngam-ho-so-khach-mon-moi-cho-20250108224329487.htm
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