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2.12 The premium for a stand -alone policy usually increases when the insured 
crosses into the next age-band upon the renewal of the policy. For example, 
from the ages of 21 to 40 years , the insured  may need to pay S$21.50 per month  
for S$100 per day benefit . From the ages of 41 to 50 years , he may need to pay 
S$33.50 per month , and so on. In other words, the premium increases with  age.  
 
2.13 The insured can have a choice of different plans provid ing varying amounts of 
benefits , and may include his spouse and children under the cover. The policy 
is usually automatically renewable on an annual basis up to a specified age (e.g. 
65, 70 or 75 years ). Normally, the cover age is 24-hour, worldwide basis.  
 
C2. Hospital Cash Insurance Riders  
 
2.14 Hospital Cash Insurance can also be issued as a rider attached to a basic policy, 
such as a Life Insurance polic y (e.g. Whole Life Insurance, Endowment 
Insurance or  Critical Illness Insurance policy ). The rider usually expires when 
the insured reaches a specified age (e.g. 65, 70 or 75 years ) or on the maturity 
of the policy, whichever is the earlier.  Thus , the term of this rider cannot be 
longer than that of the basic policy , since the rider cannot stand on its own.  
 
D. Underwriting  
 
2.15 Owing  to its small premium s, Hospital Cash Insurance p olicy is usually not 
underwritten. Pre -existing medical conditions are permanently excluded under 
the policy . 
 
  

Health Insurance   
146 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] E. Exclusions  
 
2.16 The common  exclusions of a Hospital Cash Insurance policy include:  
(a) pre-existing medical condition that the insured knew existed or has 
received treatment and/or medical advice;  
(b) pre-existing physical defect or infirmity, unless declared to and accepted by 
the insurer ; 
(c) self-inflicted injuries or suicide , while sane or insane;  
(d) Human immunodeficiency virus (HIV) or any HIV related illness, including 
Acquired Immune Deficiency Syndrome (AIDS) or any illness arising from 
it; 
(e) sexually transmitted disease;  
(f) mental/nervous dis order, drug addiction, intoxication, alcoholism, obesity, 
weight reduction/improvement, bulimia, anorexia nervosa, preventive 
treatment, such as vaccination or acupuncture;  
(g) illegal or unlawful act of the insured;  
(h) pregnancy, miscarriage, childbirth, abortio n, birth control or infertility;  
(i) routine physical or any other medical examination not relating to any health 
impairment;  
(j) cosmetic or plastic surgery, circumcision, congenital condition, dental work 
or myopic treatment;  
(k) war and related operations;  
(l) nuclear weapons material, ionising or radiation;  
(m) strike , riot  and civil commotion;  and 
(n) participation in hazardous sports like skiing or sky -diving, aerial activities 
other than air travel as a fare -paying passenger  of a licensed aircraft , driving 
or riding in any kind of race,  motor -cycling  or pillion riding.  
 
2.17 These  are just some of the common exclusions , and they vary from insurer to 
insurer.  
 
F. Termination Of Cover  
 
2.18 A Hospital Cash Insurance cover will terminate when one of the following 
events  occurs : 
(a) the premium is not paid at the end of the grace period;  
(b) the insured reaches the expiry age as stated in the policy ; 
(c) the per lifetime limit is reached;  
(d) the basic policy lapses or matures;  or 
(e) the insured dies.  
 
  

7. Other Types of Health Insurance  
 
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                 147  
G. Claims  
 
2.19 In the event of a claim, the insurer will require submission of the following 
supporting documents:  
(a) claim form; and 
(b) hospital discharge summary  and bills. 
 
 
2.20 These are the usual documents that the insured is required to submit. Note that 
the insurer reserves the right to call for additional documentary evidence, such 
as the Attending Physician’s Report  and any other relevant supporting 
documents.  
 
 
3.


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Note that 
the insurer reserves the right to call for additional documentary evidence, such 
as the Attending Physician’s Report  and any other relevant supporting 
documents.  
 
 
3. MEDICAL EXPENSE BENEFITS UNDER TRAVEL INSURANCE  
 
3.1 Travel Insurance can be issued on an individual or group basis to cover any 
losses, liabilities , medical expenses and other travel inconveniences suffered 
by an individual while travelling  outside Singapore . In thi s section, we will focus 
our discussion on the medical and related benefits offered only under a Travel 
Insurance policy. The other benefits are discussed in detail in “Personal General 
Insurance  (PGI) ” Study Guide  published by the Singapore College of Ins urance 
Limited.  
 
3.2 The medical benefits offered by a Travel Insurance policy usually include:  
▪ medical expenses  and other related benefits;  
▪ hospital confinement allowance;   
▪ emergency medical evacuation; and  
▪ repatriation . 
 
A. Medical Expense s & Other Related Benefit s 
 
3.3 Travel Insurance will reimburse most of the non-elective overseas medical and 
treatment expenses necessarily and reasonably incurred by the insured person 
for sustaining  injury or sickness (as defined in the policy) as follows:  
▪ medical expenses, such as clinical, hospital, surgical, nursing, ambulance 
and medical supply charges, and emergency accidental dental and 
miscarriage expenses, including any follow -up medical expenses in 
Singapore incurred within a certain specified perio d (usually 30 days) after 
the insured person returns from his trip; and   
▪ expenses incurred for treatment by Traditional Chinese Medicine physician, 
including acupuncturist, bonesetter, chiropractor, herbalist or 
physiotherapist, up to a limit (e.g.  S$750) as specified by some insurers;  
 
subject to an overall limit of indemnity (e.g. as much as S$2,000,000).  
 
  
CLAIM 
F

Health Insurance   
148 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] 3.4 Because there is typically no age limit to apply for travel insurance policy, 
insurer sets lower benefit limit s for child ren (below age 18) and elderly person 
(usually above the age of 70 years) if insured under  such a policy.  
 
3.5 Traditionally excluded from travel policies, some insurers are now extending 
coverage for pre -existing medical conditions to travel policies with either a 
higher premiu m and/or simple health questions.  
 
3.6 Reimbursement is also made for the following:  
▪ reasonable additional accommodation and travelling expenses necessarily 
incurred by the insured person (and a travel companion if required) to 
remain in the overseas country of visit for medical treatment on the written 
advice of a medical practitioner, up to a limit (e.g. S$25,000) ; and  
▪ hospital visit – reasonable travel and accommodation expenses necessarily 
incurred by one relative or friend of the insured person who has been 
hospitalised overseas for more than five days for example, to visit and stay 
with him until he is medically fit to return home, up to a limit (e.g. S$10,000) . 
 
B. Hospital Confinement Allowance  
 
3.7 The insured person is entitled to an amount of daily cash payment (e.g. S$200 
per day) that he is hospitalised abroad up to a certain period (e.g. 100 days) or 
up to a certain amount (e.g. S$20,000), in addition to any medical expenses 
which he has claimed. The benefits are payable upon his return to Singapore, 
when he submits a claim with all relevant supporting documents of evidence to 
the insurer.  
 
3.8 For hospitalisation in Singapore where t reatment is sought within a certain 
period (e.g. seven days) upon return, the limits are generally lower (e.g. S$100 
per day payable up to 10 days).  
 
3.9 Some insurers provide double benefit for overseas hospitalisation in an 
Intensive Care Unit resulting from  an accident up to a certain period (e.g. 10 
days).  
 
C. Emergency Medical Evacuation  
 
3.10 This covers the cost of any emergency medical evacuation. Emergency medical 
evacuation means that, in the event of a critical situation in which the insured 
person suffers a serious illness or injury abroad, and has to be evacuated to 
another place to seek  emergency medical treatment, because the local medical 
services are inadequate or unavailable.  
 
3.11 The insurer contracts a specialist company to provide emergency medical 
evacuation.


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3.11 The insurer contracts a specialist company to provide emergency medical 
evacuation. It is a requirement in the policy that the insured person must contact 
such specialist company  which  shall then decide whether or not the insured 
person will require emergency medical evacuation. For this purpose, a  24-hour 
multilingual helpline or hotline phone number of such a specialist company is 
specified in the policy , as well as a handy card, which a policyholder can bring 
along for his trip .  

7. Other Types of Health Insurance  
 
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                 149  
3.12 There is usually a maximum benefit limit (e.g. S$500,000) payable for the lower 
coverage plan. However, for the higher coverage plan , the coverage amount is 
usually unlimi ted. 
 
3.13 An important aspect of having emergency assistance cover is 
that it gives further peace of mind to the insured person if he 
suffers a serious illness or injury in an unfamiliar  environment , 
knowing that help will be on the way with just a phone call away.  
 
D. Repatriation  
 
3.14 Travel Insurance covers the expenses incurred in emergency medical 
repatriation and repatriation of body remains.  
 
3.15 Emergency medical repatriation occurs when , as a result of  an unfortunate 
illness or accident abroad, the insured has to be repatriated  to his country of 
origin ( e.g. return  to Singapore ). The decision as to whether or not he should 
be repatriated would strictly rest with the attending medical doctor or the 
insurer’ s contracted specialist company.  
 
3.16 Repatriation of remains means the transportation of and return of the deceased 
insured’s mortal remains to his country of origin . 
 
3.17 There is a maximum benefit limit (e.g. S$30,000) payable for the lower coverage 
plan.  Howev er, for the higher coverage plan, the coverage amount is usually 
unlimited . 
 
F. Exclusions  
 
3.18 Travel Insurance usually does not cover any claims directly or indirectly arising 
from or in connection with:  
(a) war, invasion, act of foreign enemy, hostilities or warlike operations 
(whether war be declared or not), civil war, mutiny, rebellion, revolution, 
insurrection or military or usurped power;  
(b) ionising radiation or contamination by radioactivity from any nucl ear fuel 
or from any nuclear waste from the combustion of nuclear fuel;  
(c) participation in civil defence, police, military, naval or air force service or 
operation, or national service in accordance with the Enlistment Act 1970 ; 
(d) self-inflicted injury, suicid e or attempted suicide, while sane or insane, 
mental or physical defect or infirmity, insanity or nervous disorder, 
intoxication or use of non -prescription drugs;  
(e) routine health check -up, or cosmetic (aesthetic) or plastic surgery;  
(f) sexually transmitted dis ease, AIDS and HIV conditions or AIDS related 
infections;  
(g) pregnancy or childbirth or any sickness associated with pregnancy or 
childbirth;  
(h) any pre -existing condition  (except for some policies, subject to Section 4.5 
above)  for which the insured person rece ived medical treatment, diagnosis, 
 

Health Insurance   
150 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] consultation or prescribed drugs within the 12 (or six) months’ period 
before the commencement date of the policy period of insurance;  
(i) driving or riding in any kind of race, engaging in any professional sport, ice 
or wint er sport, mountaineering requiring the use of guides and ropes, or 
underwater activity involving the use of underwater breathing apparatus;  
(j) aerial activity other than air travel as a fare -paying passenger in a licensed 
passenger -carrying aircraft;  
(k) direct p articipation in criminal, unlawful or terrorist act, or strike, riot or civil 
commotion;  
(l) any event including strike, riot, civil commotion, health threatening 
situation, natural disaster published by the mass media or through advisory 
of the authority, unl ess the policy already issued or the trip already 
commenced before the date of publication or advisory;  or 
(m) travel booked or undertaken against medical advice, or for the purpose of 
obtaining or seeking any medical care or treatment abroad . 
 
3.19 Note that the exclusions, restrictions and limitations vary from insurer to 
insurer.   
 
 
4.


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3.19 Note that the exclusions, restrictions and limitations vary from insurer to 
insurer.   
 
 
4. GROUP DENTAL CARE INSURANCE  
 
4.1 Dental Care Insurance is usually o ffered on a group basis and without 
underwriting. Most insurers issue it as a rider attached to a Group Hospital and 
Surgical Insurance policy . Like all group policies, only employees who are 
actively at work can be covered under this policy , and it is usually on a non -
contributory basis. Coverage is 24 -hour , worldwide basis. The policy is usually 
issued for a period of two years and thereafter, renewable every one or two 
years , depending on the insurer . 
 
A. Benefits Offered  
 
4.2 The benefits provided are very comprehensive and include dental procedures 
ranging from simple scaling and polishing to root canal treatment and wisdom 
tooth extraction. Appendix 7A is a sample of the Schedule of Allowances 
specifying  the benefits/procedures covered.   
 
4.3 The Schedule of Allowances in Appendix 7A also shows one of the ways in 
which the insurer reimburses the insured for dental expenses incurred. The 
basis of reimbursement is based on the limits as specified in the Schedu le of 
Allowances. There is no annual claim limit and also no restriction on the 
number of visits per policy year. For example, an employee can go to the 
insurer’s panel of dentists for cleaning and polishing twice a year. The cost of 
each treatment is S$40 for example , but he will not be required to pay a single 
cent, as the amount will be born e by the insurer.  
 
  
 
 
 
 
 
 

7. Other Types of Health Insurance  
 
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                 151  
4.4 Instead of setting benefit limits for each treatment/procedure, some insurers set 
an overall limit (e.g. S$200) that each insured employee may claim during each 
policy year. Once this limit is reached, the insured employee will have to pay 
from his own pocket for any treatment/procedure received.  
 
4.5 Note also that pre -existing dental conditions are usually covered as well.  
 
B. Flexibil ity 
 
4.6 Most insurers  that issue Group Dental Care Insurance policies do not have their 
own panel of dentists. As such, the insured employees can visit their own 
dentist s for treatment s. Insurers who have their own panel of dentists also allow 
the insured employees to go to their own dentist s, but will usually reimburse 
them up to the maximum limit  as stated in the Schedule of Allowances. The 
employee will have to pay the difference from  his own pocket.   
 
4.7 Most insurers also allow the coverage to be extended to cover the insured 
employee’s family members, namely  spouse and children.  
 
C. Exclusions  
 
4.8 Like all other insurance  cover s, Group Dental Care Insurance policies also 
impose certain exclusions on the cover provided. Some common exclusions 
include:  
(a) dental procedures that are not specified in the Schedule of Allowances;  
(b) hospital charges;  
(c) injuries arising directly or indirectly from war (declared or undeclared), 
revolution , or any warlike operation ; 
(d) medicine given;  
(e) treatment which is purely cosmetic in nature;  
(f) treatment resulting from self -inflicted injury , while sane or insane;  and 
(g) replace ment of broken, lost or stolen dentures.  
 
4.9 These are the general exclusions. You need to find out the specific exclusions 
under your insurer ’s policies , as the exclusions vary among the insurers . 
 
D. Limitation Clause  
 
4.10 All Group Dental Care Insurance policies include this Limitation Clause , to bring 
to the attention of the insured persons (employees) that the  reimbursement s 
under their policies will be reduced by benefits claimable under:  
(a) the Work  Injury  Compensation Insurance  policy ; 
(b) any government or public programme of dental or medical benefits; or  
(c) any other group or individual Health or Dental Care Insurance  policy . 
 
  
 

Health Insurance   
152 Copyright reserved by the Singapore College of Insurance Limited [Version 1.


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Health Insurance   
152 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] E. Termination Of Cover  
 
4.11 Cover for each individual insured employee under a Group Dental Care 
Insurance policy will automatically terminat e on the earliest of the following 
dates:  
(a) the date of termination of the insured employee’s active full -time 
employment with the policy  owner (employer);  
(b) the date of termination of the policy;  
(c) the date of expiration of the period for which the last premium payment is 
made in respect of the insured employee’s cover;  
(d) the date on which the insured employee enters full -time military, naval, air 
or police service , except during  peacetime  National Service reservist duty 
or training  in accordance with the Enlistment Act 1970 ; or 
(e) the date of expiration of the period within which the insured employee 
reaches a specified age ( e.g. 65 years ). 
 
F. Claims  
 
4.12 For any insurer that has a panel of dentists, the insurer will issue a membership 
card or certificate to every individual insured employee who will need  to 
produce  it, whenever he visits the dental clinic for treatment. In such a case, the 
dental clinic will bill the insurer direc tly, and the employee need not pay a single 
cent nor file any claim with the insurer.  
 
4.13 On the other hand, if the insurer does not have a panel of doctors , or the 
employee decides to use his own dentist, he will have to make the payment to 
the clinic first, and then file a claim with the insurer  to seek reimbursement in 
accordance with the policy . Normally, the insurer will require the following 
documents to be produced:  
▪ completed claim form; and  
▪ original receipts and itemised bills.  
 
4.14 The insurer requires the employer to submit the se documents within a specific 
period  (e.g. 2 1 days from the date of treatment).   
 
  
 CLAIM  
FO

7. Other Types of Health Insurance  
 
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                 153  
APPENDIX  7A 
 
ABC Insurance Company (Singapore) Ltd  
21 Any Street, ABC Centre, Singapore 654321  
Tel: (65) 6789 8181   Fax: (65) 6789 8282  
 
GROUP DENTAL INSURANCE  
 
 
SCHEDULE OF ALLOWANCES  
 
 
Benefits/Procedures    
Non-Panel   
Panel  
  Dentist Claim 
Limit  Dentist Claim 
Limit  
  S$ S$ 
    
Examination     
Initial   15.00  As charged  
    
X-Ray    
Intraoral   12.00  As charged  
Bitewing   12.00  As charged  
Panorex   32.00  As charged  
    
Test & Laboratory     
Biopsy & examination of tissue   48.00  As charged  
    
Prophylaxis (cleaning, polishing, scaling and fluoride 
treatment)     
Routine   40.00  As charged  
Complex   60.00  As charged  
    
Fluoride Treatment     
Fluoride Application   22.50  As charged  
    
Fillings (Silver) – For Posterior Teeth Only     
Amalgam – one surface   16.00  As charged  
Amalgam – two surfaces   24.00  As charged  
Amalgam – three or more surfaces   32.00  As charged  
Reinforced Pin   9.00 As charged  
    
Fillings (Tooth -Coloured Material) – For Anterior Teeth Only     
One surface   30.00  As charged  
Two surfaces   40.00  As charged  
Three or more surfaces   50.00  As charged  
    
Gold Inlay Restorations     
Inlay, gold – one surface   120.00  As charged  
Inlay, gold – two surfaces   160.00  As charged  
Inlay, gold – three or more surfaces   200.00  As charged  
    
Pulpotomy     
Pulpotomy   40.00  As charged  
Pulp cap   20.00  As charged  
    
Root Canal Treatment     
Single root canal filling   150.00  As charged  
Double root canal filling   220.00  As charged  
Three or more canals   350.00  As charged  
    
Extractions     
Routine (simple) – each tooth   30.00  As charged


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Health Insurance   
154 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] SCHEDULE OF ALLOWANCES  
 
 
Benefits/Procedures    
Non-Panel  
Dentist  Claim 
Limit  
S$  
       Panel  
  Dentist  Claim 
Limit  
S$ 
Surgical Extractions     
Erupted tooth or root   120.00  As charged  
Soft tissue impaction   160.00  As charged  
Part bony impaction   250.00  As charged  
Completely bony impaction   320.00  As charged  
Oral antral root recovery   144.00  As charged  
Closure of oral antral fistula   64.00  As charged  
Removal of labial frenum   40.00  As charged  
    
Alveoplasty     
Per quadrant, in connection with extractions   30.00  As charged  
Per quadrant, not in connection with extractions   42.00  As charged  
Complete alveoplasty involving more than one quadrant   160.00  As charged  
    
Excision Of Tumour     
Excision of tumour   76.00   As charged  
    
Fracture Of Jaw     
Simple   500.00  As charged  
Compound   600.00  As charged  
    
Repair Of Prosthetic Appliance     
Repair of broken complete or partial denture   20.00  As charged  
Repair denture & replace broken tooth   40.00  As charged  
Adding tooth to partial denture to replace extracted tooth   27.00  As charged  
Adding tooth to partial denture plus clasp   54.00  As charged  
    
Space Maintainers     
Fixed band type (uni or bilateral)   135.00  As charged  
Removal in acrylic ( uni or bilateral)   67.00  As charged  
    
Periodontal Treatment     
Root planning per tooth   24.00  As charged  
Root planning per quadrant   72.00  As charged  
    
Miscellaneous     
Tooth replantation (of patient’s own natural tooth)   144.00  As charged  
Tooth replantation (of patient’s own natural tooth, metal implant not 
covered)   144.00  As charged  
    
 
Note: No amount is chargeable if the insured employee visits a dentist within the panel 
of approved dentists. For any insured employee who visits a dentist outside of the panel 
of approved dentists, the claim limits are as specified  in th is Schedule of Allowance . 
 
 
 
 


22
OTHER TYPES OF HEALTH INSURANCECHAPTER
07
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
How a Hospital Cash 
(Income) Insurance policy 
works?• Also known as Hospital Income.
• Insurance pays a daily cash benefit to the insured if he is hospitalised as a result 
of an injury or illness. 
• Fixed dollar amount (e.g. S$100) chosen by the insured at the inception of the 
policy. 
• Amount has no direct correlation to the actual amount of medical fees incurred. 
• Total amount paid under this policy may be more or less than the actual 
medical expenses incurred. 
• Payment of the benefit is limited to a specified number of days (e.g. 180 days) 
per hospitalisation. Some insurers may impose a lifetime limit on the number of 
days (e.g. 1,000 days) that a person may claim.
• Can be issued as a stand-alone policy or as a rider.
Conditions to be met 
before a claim can be 
admitted under a Hospital 
Cash Insurance policy• Waiting period
 »For injury.
 »For illness.
• Hospital confinement
 »Per lifetime limit.
 »Expiry age.
 »Cause. 
Features of a Hospital 
Cash Insurance policy• Per day hospitalisation benefit.
• A cap to the maximum amount payable on a single life usually expressed as a 
maximum number of days.
• Benefit is a fixed amount throughout the policy term as specified at the 
inception of the policy.
• No waiting period if the cause of hospitalisation is due to an injury. A waiting 
period is usually imposed from the date of issue or reinstatement of the policy 
if the cause of hospitalisation is due to an illness.
• Benefit payment is not affected by the payments from other Health Insurance 
policies, plans or schemes (including Medishield Life, Integrated Shield Plan and 
any Group Hospital & Surgical Insurance Scheme), i.e. it is paid on top of the 
benefits received from all other medical insurance covers.
• Cover expires at a specified age (e.g. 65, 70 or 75 years).
• Premiums may be level or increased once the insured reaches a higher age-
band.
• Yearly renewable.


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• Cover expires at a specified age (e.g. 65, 70 or 75 years).
• Premiums may be level or increased once the insured reaches a higher age-
band.
• Yearly renewable.
• Usually provides 24-hour, worldwide coverage, although some insurers limit the 
cover to certain geographical areas. 
• Usually has no cash value.  
• No assignment of the policy is allowed.
• For a policy that is in force for a consecutive period of insurance and free of any 
claim, a premium discount is usually given at renewal. This is usually called a 
”No Claim Discount”. A certain percentage (e.g. 25%) will be deducted from the 
next renewal premium, subject to conditions as imposed by the insurer.

23
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Types of a Hospital Cash 
Insurance policy• Stand-alone Hospital Cash Insurance
• Hospital Cash Insurance Riders
Common exclusions under 
a Hospital Cash Insurance 
policy/rider• Pre-existing medical condition that the insured knew existed or has received 
treatment and/or medical advice;
• Pre-existing physical defect or infirmity, unless declared to and accepted by the 
insurer;
• Self-inflicted injuries or suicide, while sane or insane;
• Human immunodeficiency virus (HIV) or any HIV related illness, including 
Acquired Immune Deficiency Syndrome (AIDS) or any illness arising from it;
• Sexually transmitted disease;
• Mental/nervous disorder, drug addiction, intoxication, alcoholism, obesity, 
weight reduction/improvement, bulimia, anorexia nervosa, preventive 
treatment, such as vaccination or acupuncture;
• Illegal or unlawful act of the insured;
• Pregnancy, miscarriage, childbirth, abortion, birth control or infertility;
• Routine physical or any other medical examination not relating to any health 
impairment;
• Cosmetic or plastic surgery, circumcision, congenital condition, dental work or 
myopic treatment;
• War and related operations;
• Nuclear weapons material, ionising or radiation;
• Strike, riot and civil commotion; and
• Participation in hazardous sports like skiing or sky-diving, aerial activities other 
than air travel as a fare-paying passenger of a licensed aircraft, driving or riding 
in any kind of race, motor-cycling or pillion riding.
Circumstances under 
which a Hospital Cash 
Insurance policy/rider will 
be terminated.• Premium is not paid at the end of the grace period;
• Insured reaches the expiry age as stated in the policy;
• Per lifetime limit is reached;
• Basic policy lapses or matures; or
• Insured dies
Documents that need to 
be submitted in the event 
of a claim under a Hospital 
Cash Insurance policy• Claim form.
• Hospital discharge summary and bills.
Note that the insurer reserves the right to call for additional documentary evidence.
Common medical benefits 
provided by a Travel 
Insurance policy• Medical expenses and other related benefits;
• Hospital confinement allowance; 
• Emergency medical evacuation; and
• Repatriation.


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Common medical benefits 
provided by a Travel 
Insurance policy• Medical expenses and other related benefits;
• Hospital confinement allowance; 
• Emergency medical evacuation; and
• Repatriation.


24
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Common exclusions for 
the medical expense 
benefits under a typical 
Travel Insurance policy• War, invasion, act of foreign enemy, hostilities or warlike operations (whether 
war be declared or not), civil war, mutiny, rebellion, revolution, insurrection or 
military or usurped power;
• Ionising radiation or contamination by radioactivity from any nuclear fuel or 
from any nuclear waste from the combustion of nuclear fuel;
• Participation in civil defence, police, military, naval or air force service or 
operation, or national service in accordance with the Enlistment Act 1970;
• Self-inflicted injury, suicide or attempted suicide, while sane or insane, mental 
or physical defect or infirmity, insanity or nervous disorder, intoxication or use 
of non-prescription drugs;
• Routine health check-up, or cosmetic (aesthetic) or plastic surgery;
• Sexually transmitted disease, AIDS and HIV conditions or AIDS related 
infections;
• Pregnancy or childbirth or any sickness associated with pregnancy or childbirth;
• Any pre-existing condition (except for some policies, subject to Section 4.5 
above) for which the insured person received medical treatment, diagnosis, 
consultation or prescribed drugs within the 12 (or six) months’ period before 
the commencement date of the policy period of insurance;
• Driving or riding in any kind of race, engaging in any professional sport, ice 
or winter sport, mountaineering requiring the use of guides and ropes, or 
underwater activity involving the use of underwater breathing apparatus;
• Aerial activity other than air travel as a fare-paying passenger in a licensed 
passenger-carrying aircraft;
• Direct participation in criminal, unlawful or terrorist act, or strike, riot or civil 
commotion;
• Any event including strike, riot, civil commotion, health threatening situation, 
natural disaster published by the mass media or through advisory of the 
authority, unless the policy already issued or the trip already commenced 
before the date of publication or advisory; or
• Travel booked or undertaken against medical advice, or for the purpose of 
obtaining or seeking any medical care or treatment abroad.
Note that the exclusions, restrictions and limitations vary from insurer to insurer.
How the benefits are 
paid under Group Dental 
Insurance?• Based on a Schedule of Allowances
 »One of the ways in which the insurer reimburses the insured for dental 
expenses incurred.
• Basis of reimbursement is based on the limits as specified in the Schedule of 
Allowances.
Limits to the benefits 
that one is entitled to 
claim under Group Dental 
Insurance.• Some insurers set an overall limit (e.g. S$200) that each insured employee may 
claim during each policy year.
Common exclusions under 
a Group Dental Insurance 
policy• Dental procedures that are not specified in the Schedule of Allowances;
• Hospital charges;
• Injuries arising directly or indirectly from war (declared or undeclared), 
revolution, or any warlike operation;
• Medicine given;
• Treatment which is purely cosmetic in nature;
• Treatment resulting from self-inflicted injury, while sane or insane; and
• Replacement of broken, lost or stolen dentures.
Note that it may vary from insurer to insurer.
How the limitation 
clause of a Group Dental 
Insurance policy works?Reimbursements under their policies will be reduced by benefits claimable under:
• Work Injury Compensation Insurance policy;
• Any government or public programme of dental or medical benefits; or
• Any other group or individual Health or Dental Care Insurance policy.

25
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Circumstances under 
which a Group Dental 
Insurance policy will be 
terminated• Date of termination of the insured employee’s active full-time employment with 
the policy owner (employer);
• Date of termination of the policy;
• Date of expiration of the period for which the last premium payment is made in 
respect of the insured employee’s cover;
• Date on which the insured employee enters full-time military, naval, air or police 
service, except during peacetime National Service reservist duty or training in 
accordance with the Enlistment Act 1970; or
• Date of expiration of the period within which the insured employee reaches a 
specified age (e.g. 65 years).
Earliest of the above dates.
Claim procedures for 
a Group Dental Care 
Insurance claimFor any insurer that has a panel of dentists:
• Insurer will issue a membership card or certificate to every individual insured 
employee who will need to produce it, whenever he visits the dental clinic for 
treatment.


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• Dental clinic will bill the insurer directly, and the employee need not pay a single 
cent nor file any claim with the insurer.
If the insurer does not have a panel of doctors or the employee decides to use his 
own dentist:
• Make the payment to the clinic first, and then file a claim with the insurer to 
seek reimbursement in accordance with the policy.
Insurer requires the employer to submit these documents within a specific period 
(e.g. 21 days from the date of treatment)
Types of documents that 
need to be submitted 
for a Group Dental Care 
Insurance claim• Completed claim form; and 
• Original receipts and itemised bills.


8. Manage d Healthcare  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   155  
 
      CHAPTER 8  
MANAGED HEALTHCARE  
 
 
 
CHAPTER OUTLINE  
 
1. Introduction  
2. What Is Managed Healthcare (MHC)?  
3. How Does MHC Work?  
4. What Are The Common Types Of MHC Plans?  
5. Choice Of Providers Versus Cost Control  
6. Managed Healthcare (MHC) Insurance  
7. MHC Model In Singapore  
 
 
LEARNING OUTCOMES  
 
After studying  this chapter, you should be able to:  
▪ know  what MHC is 
▪ describe how MHC works  
▪ list the four common payment methods used by  Managed 
Healthcare Organisations ( MHCOs ) and understand how they work:  
- capitation  
- discounted -fee-for-service  
- salary  
- fee schedule  
▪ list the three common types of MHC plans and describe how each of them work s  
▪ describe how the four basic types of Health Maintenance Organisations (HMOs) differ 
from each other:  
- Staff Model HMO  
- Group  Model HMO  
- Network Model HMO  
- Independent Practitioners Association (IPA) HMO  
▪ rank in ascending or descending order the degree of control the Insurers/ MHOs have 
over cost and the choice of providers  
▪ list some of the ben efits provided under a MH C Insurance policy  
▪ know the elements of co -insurance and deductible for MHC Insurance  
▪ list the common exclusions under a typical M HC Insurance policy  
▪ know the underwriting requirements for MHC Insurance  
▪ state the procedure s for claims  under a MHC Insurance policy  
▪ have a view of the MHC scheme available locally  
 

Health Insurance   
156 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] Contents  
CHAPTER OUTLINE  ................................ ................................ ................................ .........  155 
LEARNING OUTCOMES  ................................ ................................ ................................ .. 155 
1. INTRODUCTION  ................................ ................................ ................................ ....... 157 
2. WHAT IS MANAGED HEALTHCARE (MHC)?  ................................ ..........................  157 
3. HOW DOES MHC WORK?  ................................ ................................ ........................  157 
A. Accessibility  ................................ ................................ ................................ ....... 157 
B. Cost  ................................ ................................ ................................ ....................  158 
C. Quality Of Care  ................................ ................................ ................................ .. 159 
4. WHAT ARE THE COMMON TYPES OF MHC PLANS?  ................................ ............  159 
A. Health Maintenance Organisation (HMO)  ................................ ........................  159 
A1. Staff Model HMO  ................................ ................................ .......................  160 
A2. Group Model HMO  ................................ ................................ ....................  160 
A3. Network Model HMO  ................................ ................................ .................  161 
A4. Independent Practitioners Association (IPA) Model HMO  .......................  162 
A5. Mixed Model HMOs  ................................ ................................ ...................  162 
B. Preferred Provider Organisations (PPOs)  ................................ ........................  162 
C. Point -of-Service (POS) Plan  ................................ ................................ ..............  163 
5. CHOICE OF PROVIDERS VERSUS COST CONTROL  ................................ ...............  163 
6. MANAGED HEALTHCARE (MHC) INSURANCE  ................................ ......................  164 
A. Benefits Offered  ................................ ................................ ................................  164 
B. Elements Of Co -insurance & Deductible ................................ ..........................  164 
C. Exclusions  ................................ ................................ ................................ ..........  164 
D. Underwriting  ................................ ................................ ................................ ..... 165 
E. Claims  ................................ ................................ ................................ ................  165 
7. MHC MODEL IN SINGAPORE  ................................ ................................ ..................  166 
 


8. Manage d Healthcare  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   157  
1. INTRODUCTION  
 
1.1 Managed Healthcare (MHC) schemes have evolved in the market as a response 
to increasing medical costs.


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4]                                   157  
1. INTRODUCTION  
 
1.1 Managed Healthcare (MHC) schemes have evolved in the market as a response 
to increasing medical costs. MHC plans are usually managed or run by insurers 
as insurance -backed plans. Locally, only group MHC insurance is available.  
Such policies are  often  purch ased by employers as part of their Employee 
Benefit package , and as an alternative to traditional Group Health Insurance 
plans. In this chapter, we will first look at the concept and various models of 
MHC , before we discuss briefly the MHC insurance  covers  that are available in 
the market.  
 
 
2. WHAT IS MANAGED HEALTHCARE  (MHC) ? 
 
2.1 MHC refers to an overall strategy for containing medical care costs , while 
assuring that people receive appropriate medical care.  It will pay for most of the 
medical bills , when an individual  sees a General Practitioner (GP) , specialist or 
receive s treatment in  a hospital.  Such strategies make use of a number of MHC 
techni ques related to how medical care is accessed, provided and paid for.  
 
 
3. HOW DOES MHC WORK?  
 
3.1 MHC providers set up a healthcare network to manage the accessibility, cost  
and quality of care of its members. They negotiate and contract with doctors, 
hospitals, clinics, and other health care providers , such as pharmacies, 
laboratories, X-ray centr es, and medical equipment vendors , in exchange for 
more patients directed to th em. 
 
3.2 MHC works  through carefully managing the following three components , in 
order to contain and control healthcare expenditure:  
▪ accessibility ; 
▪ cost; and  
▪ quality of care . 
 
A. Accessibility  
 
3.3 In a MHC  plan, members are referred to a carefully selected network of 
healthcare providers. In some MHC plans, a member  may be required to receive 
all his healthcare services from a  particular provider within the network.  This 
doctor will be his Primary Care Phys ician (PCP).  In other managed care plans, 
he may be able to receive care from providers who are not part of the network,  
but will have to pay a larger share of the cost to receive those services.  
 
3.4 As the emphasis of MHC is on primary and preventive care  to avoid serious 
health problems , PCPs are the backbone of many MHC plans. PCPs are valued 
because of their ability to diagnose and treat a broad range of medical 
conditions. Additionally, as they are familiar with the health conditions and  
circumstances of their patients, PCPs are often better able to ascertain the type 
of specialty care  that member s may need.  
 
 
 
 
   Accessibility  
Quality 
of Care  Cost  

Health Insurance   
158 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] 3.5 PCP is usually a general practitioner who serves as the member’s “personal 
physician”  and acts as the first contact with the MHC. If additional care is 
needed, the PCP will refer the member to a specialist within the network. Under 
most MHC plans, a member must obtain a referral from the PCP before seeing 
a specialist. As such, PCPs are often called “gatekeepers”. As gatekeepers, PCPs 
co-ordinate and manage all aspects of the members’ care. Members are 
allowed to change their PCPs.   
 
B. Cost  
 
3.6 A Managed  Healthcare Organisation (MHCO) uses various  methods to control 
increasing medical care costs . One of which is negotiated provider fees.  
 
3.7 By limiting  the number of physicians or hospitals in a provider network, the 
MHCO can negotiate the physicians’ or hospitals’ fees  and reduce the cost for 
providing medical services to its members. The MHCO is able to achieve this , 
because physicians, hospitals and o ther medical service providers are generally 
willing to reduce their fees , in exchange for the increase in patient volume that 
a MHC network can provide them.  
 
3.8 The four common payment  methods used by MHCO are as follows:  
▪ capitation;  
▪ discounted -fee-for-service;  
▪ salary; and  
▪ fee schedule.  
 
(a) Capitation  
Under this method, the MHCO pre -pays its providers a fixed amount for 
each member’s medical care usually on a monthly basis. The provider is 
paid the same amount each month , regardless of how often the member 
receives medical attention or the cost of that medical attention.


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The provider is 
paid the same amount each month , regardless of how often the member 
receives medical attention or the cost of that medical attention. The fixed 
fee may not be the same for al l the MHCO members.  
 
(b) Discounted -Fee-For-Service  
MHCO pays its physicians a certain percentage of their normal fees  (e.g. 
90% of the normal fee ), thereby achieving a discount of 10% on the 
physician s’ fees.  
 
(c) Salary  
This method is used in the Staff Model HMO ( Health Maintenance 
Organisation ). Under this method, the HMO compensate s the physicians 
with a fixed salary. These salaries are based on the average earnings of 
local physicians in the same field or specialty. The HMO also pay s the 
physicians performance -based bonuses or gives incentive pay ments . 
 
(d) Fee Schedule  
Under this method, the MHCO place s caps or limits on the dollar amounts 
that will be reimbursed for covered medical procedures and services . 
When using this fee schedule payment structure, the MHCO will pay no 


8. Manage d Healthcare  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   159  
more than the specified maximum fee allowed for each procedure. As this 
fee structure will result in a smaller reimbursement of fees for physicians 
who charge higher -than -average fees, it may encourage the provision of 
unnecessary medical services  (e.g. physicians asking patients to go for 
more tests than necessary  or return for follow -up checks ). 
 
3.9 Other methods used by the MHCO to control medical care costs include 
Utilisation Management and risk sharing agreements.  
 
C. Quality Of Care  
 
3.10 To ensure that the quality of care is not compromised with the cost -containment 
effort, members can be assured that the MHCO contract s with only those 
healthcare providers that possess the requisite skills, training and licen ces to 
provide the necessary se rvices to them . These providers must provide the 
medically necessary services under prevailing professional standards of care. 
The MHCO also develop s quality assurance programmes usually in co -
operation with the providers to guarantee availability, accessibility and 
continuity of care to its members. In fact, the MHCO  is just as much concerned 
about the quality of care delivered , as cost control for a good reputation is what 
attracts new members and keeps existing members.  
 
 
4. WHAT ARE THE COMMON TYPES OF MHC PLANS?   
 
4.1 The three common types are:  
▪ Health Maintenance Organi sation (HMO);  
▪ Preferred Provider Organi sation (PPO); and 
▪ Point -of-Service (POS) plan.  
 
4.2 Let us look at each of them in turn.  
 
A. Health Maintenance Organisation (HMO)  
 
4.3 A member  enrolled in a  Health Maintenance Organi sation  (HMO) will need to 
receive most or all of his health care from a network provider. HMOs re quire 
that the member choose s a primary care physician  (PCP who is most often a 
family doctor, or paediatrician for children) who is responsible for managing 
and coordinating all of his health care.  
 
4.4 If the member needs care from a physician specialist in the network or a 
diagnostic service such as a lab oratory  test or X-ray, the PCP will have to 
provide a referral. If the member  does not have a referral or choose s to go to a 
doctor outside of his health plan’s network, he will most likely have to pay all 
or most of the cost s for that care , unless it was pre-authorised by the HMO, or 
deemed as an emergency.   
 
4.5 The HMO is the most restrictive type of health plan , because the member has 
the least choice in selecting his healthcare provider.   
 


Health Insurance   
160 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] 4.6 There  are four basic types of HMO as follows:  
▪ Staff Model HMO;  
▪ Group Model HMO;  
▪ Network Model HMO; and  
▪ Independent Practitioners Association (IPA) Model HMO.  
  
A1. Staff Model HMO  
 
4.7 In a Staff Model  HMO , the HMO employs the healthcare providers who usually 
work together in a centre. The doctors  treat only  patients who are  members  of 
the HMO . The usual way to provide specialist care is to refer their patients to 
certain contracted specialist s.


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The doctors  treat only  patients who are  members  of 
the HMO . The usual way to provide specialist care is to refer their patients to 
certain contracted specialist s.  
 
4.8 A Staff Model HMO can be very effective at managing costs , as it has control 
over the physicians whom it employ s. The treatment provided or recommended 
by the physicians can be monitored very closely for adherence to the HMO’s 
guidelines. Moreover, as the physicians are paid regular salar ies, regardless of 
the number of services that they provide, the y have no financial incentive to 
over -treat the patients.  
 
4.9 Figure 8.1 is an illustration  of the Staff Model HMO.  
 
Figure 8.1: Staff Model HMO  
 
 
 
 
 
 
 
 
 
 
A2. Group  Model HMO  
 
4.10 In a Group Model HMO , the doctors and healthcare providers are not hired 
directly. It contracts with a large group medical practice to provide medical care 
services to its members  and pays the group  in bulk. The physicians decide 
within the group how the money is distributed.  
 
4.11 The group  practice in turn is responsible for:  
▪ obtaining the physicians necessary to provide the contracted services;  
▪ compensating its physicians;  
▪ providing facilities in which its physicians will perform the contracted 
services; and  
▪ arranging to provide hospital services.  
 
 
 
         HMO  
 
 
PHYSICIANS  EMPLOYS  OWNS OR 
CONTRACTS 
WITH  
 

8. Manage d Healthcare  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   161  
4.12 As with the Staff Model HMO , the physicians only see patients that signed up 
for the HMO that contracted them  and has the same effectiveness at managing 
cost. 
 
4.13 Figure 8.2 is a graphical  illustration of the organisation of the Group Model 
HMO.  
Figure 8.2: Group Model HMO  
 
 
 
 
 
 
 
A3. Network Model HMO  
 
4.14 The Network Model HMO is similar to the Group Model HMO in that it contract s 
for medical care services , instead of employing the physicians. Instead of 
contracting with one or just a few large multi -speciality group practices, it 
contracts with a relatively large number of group practices, some of which may 
have a single speciality. Some Network Model HMOs may even contract with 
individual physicians , so that they can offer a comprehen sive range of medical 
care services to their members. The Network Model HMO also arranges for the 
provision of hospital services to its members.  
 
4.15 Figure 8.3 is a graphical  illustration of the organisation of the Network Model 
HMO . 
Figure 8.3: Network Model HMO  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
HMO  
 
    GROUP PRACTICE  
 
 
 
PHYSICIANS  EMPLOYS  
 CONTRACTS 
WITH  ARRANGES 
FOR 
 
 
 
 
 
GROUP  
PRACTICE  
 
PHYSICIANS  
 
 
GROUP  
PRACTICE  
 
PHYSICIANS  
     HMO  

Health Insurance   
162 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] 4.16 Physicians  operate out of their own offices or the facilities provided to them by 
their group practice. The Network Model HMO physicians do no t necessarily 
obtain all their patients from a particular HMO. Some network physicians may 
contract to provide services to more than one HMO. They may also belong to 
one o r more PPO networks  or may treat other walk -in private patients . For this 
reason , and because the HMO arranges for hospital services , rather than the 
physicians, the Network Model HMO do es not have as tight a control over 
Utilisation Management1 as the two models discussed earlier.  
 
A4. Independent Practitioners Association (IPA) Model HMO  
 
4.17 Here , the HMO contracts an independent practice association that works 
similarly to a multi -speciality phys ician group practice, except it s members are 
allowed to treat non -HMO patients. Under this model, the primary care 
physicians are allowed to refer employees to medical services outside the 
network . However, the HMO m ight not provide as much coverage as it would 
for the employee s who had stayed within the network.  
 
A5. Mixed Model HMOs  
 
4.18 The four HMO models as described so far are the traditional HMOs.


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A5. Mixed Model HMOs  
 
4.18 The four HMO models as described so far are the traditional HMOs. An 
increasing number of HMOs are now operating as mixed -model plans, which 
means that the organisation of the plan is a combination of two or more of the 
four types of plans which we have already discussed.  
 
4.19 For example, a plan may have been established as a Staff Model HMO , but at a 
later time, it may decide to expand its capacity by adding physicians under an 
IPA arrangement. Mixed  Model HMOs are common nowadays , because they 
offer broader consumer choice of phy sicians and clinical settings.  
 
B. Preferred Provider Organisations (PPOs)  
 
4.20 A Preferred  Provider Organisation  (PPO) has negotiated contracts with a 
network of preferred providers from which a member  can choose. A member  
does not need to select a PCP and do es not need referrals to see other providers 
in the network.  However, to encourage the use of network providers and/or get 
a referral for a specialist, PPO offers “richer” benefits to members as financial 
incentives. These i nclude lower or no deductible, lower or no co -payment , and 
higher benefits. For example, if a member sees a network provider, he will not 
need to pay for the medical cost. However, if he sees a non -network provider, 
he may have to pay as much as 50% of the  total bill.  
 
4.21 PPOs  are less restrictive than HMOs in the choice of healthcare provider s. 
However, they tend to require greater "out -of-pocket" payments from the 
members.  
 
  
 
1  Utilisation Management is a programme designed to manage the use of medical services to ensure that 
a patient receives necessary, appropriate and high -quality care in a cost -effective  manner.  

8. Manage d Healthcare  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   163  
C. Point -of-Service (POS)  Plan  
 
4.22 A POS plan is a combination of a HMO and a PPO. Typically, a POS plan ha s a 
contracted provider network that functions like a HMO. A POS plan encourage s, 
but do es not require, a member to choose a PCP. A POS plan also allow s a 
member  to use a provider who is not in the network. However, if he choose s to 
go out  of the network for his care, he will pay higher co -payments and/or 
deductibles than any member who use s a PCP.  
 
4.23 The plan  is known as point -of-service, because each time a member  need s 
healthcare  service  (the time or “point” of service), he can decide to stay in the 
network to allow his PCP to manage his care service,  or to go outside the 
network on his own, without a referral from his PCP.  
 
 
5. CHOICE OF PROVIDERS VERSUS COST CONTRO L  
 
5.1 As mentioned, MHCOs help to contain the cost of healthcare by managing the 
access to providers, cost of providing healthcare , as well as the quality of care. 
Figure 8.4 illustrates the relationship between the degree of control over the 
cost and access , and their effects on the purchaser.  
 
 
Figure 8.4: Degree Of Choice Of Providers Versus Degree Of Cost Control  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
5.2 Note from Figure 8.4 that the Staff Model HMO has the greatest cost control , 
but its members have the lowest degree of choice of providers. The cost saved 
is passed on to the purchasers who are charged a lower price for participating 
in the plan. At the other extreme, there i s no control over the access to 
healthcare providers under a traditional Medical Expense Insurance , and no 
cost control too. As a result, the premium for a traditional Medical Expense 
Insurance policy is higher  as compared to the MHC plan.  
 
 
High  
Low 
Degree Of Choice of Providers  
High  
Cost Control  
Staff Model HMO  
Group Model HMO  
Network Model HMO  
IPA Model  HMO  
PPO 
Traditional Medical Expense Insurance  
POS 

Health Insurance   
164 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] 5.3 At present, no  MHC plan can offer high level of benefits, unlimited access to 
providers and low cost , all at the same time. The best  that any plan can expect 
to accomplish is two of the three features.


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The best  that any plan can expect 
to accomplish is two of the three features. Some plans will focus on costs and 
access, while others will focus o n benefits and costs , or access and benefits.  
 
6. MANAGED HEALTHCARE (MHC) INSURANCE  
 
6.1 Having seen how the different types of MHC plans  work, let us look 
at how a typical  insurer’s  MHC insurance policy in Singapore works.  
 
A. Benefits Offered  
 
6.2 For fixed annual premium s, insurers offering MHC plans may provide their 
policy owners with some or all of the coverage  as described below :  
▪ Primary Care  – provided by a wide network of genera l physicians in clinics 
all over Singapore. It includes consultation, medication, procedures and tests 
deemed medically necessary.  
▪ Specialist Care  - provided by a wide network of specialists from different 
medical specialties. It includes consultation, medication, tests and surgery 
upon referral from a  PCP.  
▪ Hospital Care  – provided for confinement in private, public or community 
hospitals. Reimburs ement for the hospital and surgical expenses will be 
subject to limits under  the insured plan.  
▪ Emergency Care  – provides 24 -hour cover for accident and emergency.  
▪ Preventive Care  − provides educational programmes , such as talks, seminars 
and workshops on n utritional counselling, etc., designed to keep members 
free from diseases.  
 
6.3 The benefits  offered by the MHCOs may differ , as some may provide only 
outpatient care , while others may provide the full spectrum of benefits. These 
benefits can also be extended to dependants. As you will see in  later chapter of 
this Study Guide , CPF members may use their Medisave to purchase MHC plans 
which are approved by the CPF Board.  
 
6.4 Like other Health Insurance policies, there is a minimum , as well as a m aximum 
entry age for MHC plans , but it usually varies among  insurers.  
 
B. Elements Of C o-insurance & Deductible  
 
6.5 Like other types of traditional Health Insurance, the elements of co -insurance 
and deductible may be found in MHC Insurance.  
 
C. Exclusions  
 
6.6 The common exclusions under a MHC Insurance policy include:   
▪ pre-existing conditions;  
▪ congenital anomaly , hereditary condition and disorder;  
▪ mental illness and personality disorder;  


8. Manage d Healthcare  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   165  
▪ infertility, sub -fertility, assisted conception treatment;  
▪ treatment of sexually transmitted disease;  
▪ Acquired lmmun e Deficiency Syndrome (AIDS), AIDS related complex or 
infection by human immunodeficiency virus (HIV);  
▪ self-inflicted injuries;  
▪ drug addiction or alcoholism;  
▪ purchase of eyewear or related eye care item s; 
▪ purchase of kidney dialysis machine, iron -lung, prosthesis and other special 
appliances;  
▪ private nursing charges;  
▪ injuries arising from direct participation in strike, riot or civil commotion;  
▪ injuries arising directly or indirectly from nuclear fallout, w ar (whether 
declared or not declared) and related risks;  
▪ childbirth and abortion or routine ante -natal and post -natal visits;  
▪ cosmetic surgery ( except for treatment necessitated by an accident);  
▪ general exclusions imposed on  Medical Expense Insurance polic ies are also 
applicable to MHC I nsurance plans ; 
▪ optional items which are outside the scope of treatment;  and 
▪ reimbursements for Work Injury Compensation Insurance and other forms 
of insurance coverage.  
 
6.7 Note that the exclusions vary from insurer to insurer. Hence, you need to find 
out what the exclusions of your insurer  are and highlight them to your clients.  
 
D. Underwriting  
 
6.8 The underwriting requirements for MHC are discussed in  later chapter of thi s 
Study Guide . They are similar to those for Medical Expense Insurance cover.  
 
E. Claims  
 
6.9 The procedure  for MHC  claims  is mainly between the MHCO and the providers. 
Members who use the in -network care are not required to file any claims with 
the insurer. It is only those who use out -of-network providers will need to file 
claims with the MHCO. The relevant supporting docum ents to be submitted for 
such a case include:  
▪ the claimant’s statement; and  
▪ original itemised medical bill.


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The relevant supporting docum ents to be submitted for 
such a case include:  
▪ the claimant’s statement; and  
▪ original itemised medical bill.  
 
 
  

Health Insurance   
166 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] 7. MHC MODEL IN SINGAPORE  
 
7.1 The MHC arrangements described above are not common in Singapore. 
Locally, e mployer s either engage MHCO or insurance company to offer 
cashless medical services to employees. Such services include cashless 
outpatient general practitioner  (GP) and specialist con sultation visits. To ensure 
the specialist cost is covered, employee needs to obtain a GP’s referral to see a 
specialist. The GP acts as a gatekeeper to minimise unnecessary specialist visit.  
 
7.2 Employees have to go to the selected panel to enjoy cashless f acilities  and the 
cost and quality of care are managed by MHCO or the insurer. If an employee 
choose s to visit a non-panel  clinic , the cost  is either not covered  or parti ally 
covered subject to co -payments and/or benefit limits.  
 
7.3 If the arrangement is u nder an insured scheme, insurer will also provide an 
added hospitalisation cover  (Group Hospital & Surgical)  which may be cashless 
with the provision of letter of guarantee to the hospital.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

26
MANAGED HEALTHCARECHAPTER
08
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Managed Healthcare 
(MHC)MHC refers to an overall strategy for containing medical care costs, while assuring 
that people receive appropriate medical care. It will pay for most of the medical 
bills, when an individual sees a General Practitioner (GP), specialist or receives 
treatment in a hospital.
How MHC works? MHC providers set up a healthcare network to manage the accessibility, cost and 
quality of care of its members. They negotiate and contract with doctors, hospitals, 
clinics, and other health care providers, such as pharmacies, laboratories, X-ray 
centres, and medical equipment vendors, in exchange for more patients directed to 
them.
Payment methods used 
by Managed Healthcare 
Organisations (MHCOs)
• CapitationMHCO pre-pays its providers a fixed amount for each member’s medical care 
usually on a monthly basis. The provider is paid the same amount each month, 
regardless of how often the member receives medical attention or the cost of that 
medical attention. The fixed fee may not be the same for all the MHCO members.
Payment methods used 
by Managed Healthcare 
Organisations (MHCOs)
• Discounted-fee-for-
serviceMHCO pays its physicians a certain percentage of their normal fees (e.g. 90% of the 
normal fee), thereby achieving a discount of 10% on the physicians’ fees.
Payment methods used 
by Managed Healthcare 
Organisations (MHCOs)
• SalaryThis method is used in the Staff Model HMO (Health Maintenance Organisation). 
Under this method, the HMO compensates the physicians with a fixed salary. These 
salaries are based on the average earnings of local physicians in the same field or 
specialty. The HMO also pays the physicians performance-based bonuses or gives 
incentive payments.
Payment methods used 
by Managed Healthcare 
Organisations (MHCOs)
• Fee schedule MHCO places caps or limits on the dollar amounts that will be reimbursed for 
covered medical procedures and services. When using this fee schedule payment 
structure, the MHCO will pay no more than the specified maximum fee allowed for 
each procedure. 
Common types of MHC 
plans• Health Maintenance Organisation (HMO); 
• Preferred Provider Organisation (PPO); and
• Point-of-Service (POS) plan. 
Four basic types of 
Health Maintenance 
Organisations (HMOs):
• Staff Model HMO• Employs the healthcare providers who usually work together in a centre. 
• Doctors treat only patients who are members of the HMO. 
• Usual way to provide specialist care is to refer their patients to certain 
contracted specialists.
Four basic types of 
Health Maintenance 
Organisations (HMOs):
• Group Model HMO• Doctors and healthcare providers are not hired directly.
• Contracts with a large group medical practice to provide medical care services 
to its members and pays the group in bulk. 
• Physicians decide within the group how the money is distributed.
Four basic types of 
Health Maintenance 
Organisations (HMOs):
• Network Model HMO• Similar to the Group Model HMO.
• Contracts for medical care services, instead of employing the physicians.


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Four basic types of 
Health Maintenance 
Organisations (HMOs):
• Network Model HMO• Similar to the Group Model HMO.
• Contracts for medical care services, instead of employing the physicians. 
• Contracts with a relatively large number of group practices, some of which may 
have a single speciality.
Four basic types of 
Health Maintenance 
Organisations (HMOs):
• Independent 
Practitioners 
Association (IPA) HMO• HMO contracts an independent practice association that works similarly to a 
multi-speciality physician group practice, except its members are allowed to 
treat non-HMO patients.
• Allowed to refer employees to medical services outside the network.
• HMO might not provide as much coverage as it would for the employees who 
had stayed within the network.

27
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Degree of control the 
Insurers/MHOs have over 
cost and the choice of 
providers
Some benefits provided 
under a MHC Insurance 
policy• Primary Care.
• Specialist Care.
• Hospital Care.
• Emergency Care.
• Preventive Care.
Elements of co-insurance 
and deductible for MHC 
InsuranceLike other types of traditional Health Insurance, the elements of co-insurance and 
deductible may be found in MHC Insurance.
Common exclusions under 
a typical MHC Insurance 
policy• Pre-existing conditions;
• Congenital anomaly, hereditary condition and disorder;
• Mental illness and personality disorder;
• Infertility, sub-fertility, assisted conception treatment;
• Treatment of sexually transmitted disease;
• Acquired lmmune Deficiency Syndrome (AIDS), AIDS related complex or 
infection by human immunodeficiency virus (HIV);
• Self-inflicted injuries;
• Drug addiction or alcoholism;
• Purchase of eyewear or related eye care items;
• Purchase of kidney dialysis machine, iron-lung, prosthesis and other special 
appliances;
• Private nursing charges;
• Injuries arising from direct participation in strike, riot or civil commotion;
• Injuries arising directly or indirectly from nuclear fallout, war (whether declared 
or not declared) and related risks;
• Childbirth and abortion or routine ante-natal and post-natal visits;
• Cosmetic surgery (except for treatment necessitated by an accident);
• General exclusions imposed on Medical Expense Insurance policies are also 
applicable to MHC Insurance plans;
• Optional items which are outside the scope of treatment; and
• Reimbursements for Work Injury Compensation Insurance and other forms of 
insurance coverage.
Note that the exclusions vary from insurer to insurer.
Underwriting 
requirements for MHC 
InsuranceSimilar to those for Medical Expense Insurance cover.
Procedures for claims 
under a MHC Insurance 
policy• Mainly between the MHCO and the providers.
• If using out-of-network providers will need to file claims with the MHCO. The 
relevant supporting documents to be submitted for such a case include:
 »Claimant’s statement; and 
 »Original itemised medical bill.
MHC scheme available in 
Singapore• Not common in Singapore.
• Employers either engage MHCO or insurance company to offer cashless medical 
services to employees.Traditional Medical Expense Insurance
PPO
POS
IPA Model HMO
Network Model HMO
Group Model HMO
Staff Model HMO
High Low
Cost ControlHighDegree of Choices
of Providers

9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         167  
      CHAPTER 9  
PART I HEALTHCARE FINANCING  
 
 
 
CHAPTER OUTLINE  
 
1. Introduction  
2. Healthcare Subsidies  
3. MediSave  
4. MediShield Life  
5.


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Introduction  
2. Healthcare Subsidies  
3. MediSave  
4. MediShield Life  
5. Integrated Shield Plans (IPs)  
 
 
LEARNING OUTCOMES  
  
After studying this chapter, you should be able to:  
▪ understand Singapore’s healthcare financing philosophy  
▪ describe the Singapore Government subsidies available  
▪ describe the following healthcare  financing scheme s: 
- Community Health Assist Scheme (CHAS)  
- MediSave  
- MediShield  Life 
- Integrated Shield Plans  
- ElderShield & ElderShield Supplements  
- CareShield Life & CareShield Life Supplements  
▪ outline how MediSave  can be used to meet a CPF member’s healthcare needs 
and buy  approved Medical Expense Insurance  
▪ explain the shift from MediShield to MediShield Life  
▪ describe the enhanced benefits  under MediShield Life  
▪ describe how MediShield Life premiums are kept affordable  
▪ explain how MediShield Life interacts with Integrated Shield Plans  
▪ know the claims process of MediShield Life,  Integrated Shield  Plans,  Medical 
Expense  Insurance and MediSave  
  

Health Insurance   
 
168 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] Contents  
CHAPTER OUTLINE  ................................ ................................ ................................ .........  167 
LEARNING OUTCOMES  ................................ ................................ ................................ .. 167 
1. INTRODUCTION  ................................ ................................ ................................ ..... 169 
2. HEALTHCARE SUBSIDIES  ................................ ................................ .....................  169 
A. Public Hospitals  ................................ ................................ ................................ . 170 
B. Other Healthcare Services  ................................ ................................ ................  171 
3. MEDISAVE  ................................ ................................ ................................ ..............  172 
A. Basic Healthcare Sum  ................................ ................................ .......................  173 
B. Uses Of MediSave  ................................ ................................ .............................  173 
C. How Much Medisave Can Be Used?  ................................ ................................ . 177 
4. MEDISHIELD LIFE  ................................ ................................ ................................ ... 179 
A. MediShield Life Premiums  ................................ ................................ ................  179 
B. MediShield Life Subsidies ................................ ................................ .................  180 
C. MediShield Life Benefits  ................................ ................................ ...................  181 
D. How Are MediShield Life Claim Payouts Computed?  ................................ ..... 182 
E. MediShield Life Fund  ................................ ................................ ........................  185 
5. INTEGRATED SHIELD PLANS (IPs)  ................................ ................................ ....... 185 
A. Integrated Structure Of IPs ................................ ................................ ................  187 
B. Standard IP  ................................ ................................ ................................ ........  189 
C. MediSave Use For IP Premiums  ................................ ................................ ....... 189 
D. Riders  ................................ ................................ ................................ .................  190 
E. Terminating or Switching IP/Switching Insurer  ................................ ...............  191 
F. Risk-Loading By Private Insurers  ................................ ................................ ...... 192 
G. Pre-Authorisation for IP, Claim Process For MediShield Life/IP, Other Private 
Insurance & MediSave  ................................ ................................ ......................  192 
APPENDIX 9A  ................................ ................................ ................................ ..................  195 
APPENDIX 9B  ................................ ................................ ................................ ..................  198 
APPENDIX 9C  ................................ ................................ ................................ ..................  200


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9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         169  
1. INTRODUCTION  
 
1.1 In this chapter, we will review the various subsidies and healthcare financing 
schemes that the Singapore Government has put in place to help Singaporeans 
meet the costs of healthcare.   
 
1.2 Through a mixed financing syste m (see Figure 9.1  below), Singapore has 
secured good healthcare outcomes for its population. For example, life 
expectancy at birth has increased from 80.3 in 2006  to 83.93 in 20221, while 
infant mortality rate    improved from 2 .6 per thousand live births to 1.8 per 
thousand live b irths2 as at 2020 . The Government has done so with a national 
healthcare expenditure of about  2.1% of the country’s Gross Domestic Product 
(GDP) in  2018, which is low among developed countries (although this is 
expected to grow with an ageing population o ver the years).  
 
Figure 9.1: Main Components in Singapore's Healthcare Financing System  
 
Source: Managing the Cost of Health Insurance in Singapore, Health Insurance 
Task Force, Singapore  
 
 
2. HEALTHCARE SUBSIDIES  
 
2.1 The Government provides funding to public healthcare institutions (e.g. public 
hospitals , national specialty centres  and polyclinics ), as well as selected private 
clinics and voluntary welfare organisations (VWOs) which offer a range of 
community and home -based care. This enables Singaporeans to have access 
to subsidised care.  
 
2.2 In many healthcare settings, a means -test is used to target subsidies, so that 
needy patients can receive more  help; lower -income patients receive more 
subsidies than higher -income patients. These targets  limited resources at those 
who need them more and  ensures that the Government subsidies are  
sustainable.  
 
1 https://www.macrotrends.net/countries/SGP/singapore/life -expectancy  
2 https://www.statista.com/statistics/624889/singapore -infant -mortality -rate/  


Health Insurance   
 
170 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] A. Public Hospitals  
 
A1. Inpatient  
 
2.3 Patients can choose different ward classes if they need to be 
admitted into  a hospital. These ward classes differ only in the type of physical 
amenities and level of comfort and  range from one bedded rooms (Class A 
wards) to rooms with multiple beds (Class  B/C wards). The standard of medical 
care is the same regardless of the ward class.  
 
2.4 The subsidies provided by the government will differ according to the ward 
class. The wards with basic amenities (e.g.  Class C wards) are heavily 
subsidised. Those who desire more amenities can choose a higher ward class 
but will receive less subsidy. Class B2 and C ward admissions (81% of public 
hospital beds) are heavily subsidised. Class B1 admissions are subsidised 20 % 
while there is no subsidy for Class A ward admissions.3 However, patients will 
be able to receive up to 80% in subsidies regardless of whether they are 
admitted to B2 or C class wards from  1 November 20224.  
 
2.5 In January 2009, means testing  in public  hospitals was introduced to better 
target the heavy subsidies for Class B2 and Class C wards at the lower -income 
group. The subsidy received  depend ed on the monthly income of the patient.  
 
2.6 Patients requiring any follow -up at the specialist outpatient clinics (SOCs) after 
their Class B2 or Class C hospitalisation will continue to receive subsidies at the 
SOCs. (Patients in Class A and Class B1 wards will continue their treatments at 
the priva te SOCs at the public hospitals, if needed ). 
 
A2. Specialist Outpatient Clinics (SOCs)  
 
2.7 For SOC services, lower - to middle -income SOC patients are subsidi sed 70% 
and 60% respectively, while the rest receive 50% subsidy5. Additionally, two 
new subsidy tiers  will be introduced in  1 January  20236: patients with a per 
capita household income above $3,300 and not more than   $6,500 (for a 
family of four, this means a total income of $13,200) will receive a subsidy of 
40% while those above $6,500  have a subsidy of 30%.


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Permanent  Residents will 
continue  to receive 25% subs idy.  
 
2.8 For standard drugs at SOCs, all lower -to middle -income subsidi sed patients 
receive a 75% subsidy for standard drugs, while the rest of the subsidi sed SOC 
patients receive a 50% subsidy. Patients who opt to be admitted to A or B1 
wards at public hospitals will be eligible for subsidies in SOC should they 
require follow -up visits at these clinics.   
 
 
3 https://www.moh.gov.sg/home/our -healthcare -system/healthcare -services -and-facilities/hospital -services  
4 https://www.moh.gov.sg/cost -financing/healthcare -schemes -subsidies/subsidies -for-acute -inpatient -care-
at-public -healthcare -institutions  
5 https://www.moh.gov.sg/cost -financing/healthcare -schemes -subsidies/subsidies -for-services -and-drugs -
at-public -healthcare -settings  
6 https://www.moh.gov.sg/cost -financing/healthcare -schemes -subsidies/subsidies -for-special ist-
outpatient -care-at-public -healthcare -institutions  
 
Medisave  
 
Hospital Bills  
 

9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         171  
2.9 The eligibility for higher subsidy is based on the household monthly income 
per person, or annual value of residence (for any household with no income).  
 
A3. Other Services  
 
2.10 Other services such as day surgery and Accident & Emergency (A&E) services 
are sub sidised up to 65% and 50% respectively.  Similar to the Inpatient Subsidy 
Framework, day surgeries will also be subsidised up to 80% for Singapore 
Citizens and up to 50% for Permanent Residents with effect from 1 November 
2022.  
 
B. Other Healthcare  Services  
 
2.11 The services provided at Government polyclinics  are subsidised at about 50% 
(75% if the patient is a child or an elderly  person ). All lower - to middle -income 
patients at the polyclinics will enjoy a 75% subsidy for all standard drugs.  
 
B1. Community Health Assist Scheme (CHAS)   
 
2.12 The Community Health Assist Scheme (CHAS) enables all Singapore Citizens, 
including Merdeka Generation (MG) and Pioneer Generation (PG) cardholders, 
to receive subsidies for medical and/or dental care * at participating General 
Practitioner (GP) and dental clinics.  This scheme has been expanded beyond 
the lower - and middle -income  group to include all Singapore Citizens. Using 
CHAS, one can also enjoy $2 to $5 fixed fee for recommended health screenings 
under  Screen for Life . 
*Only for CHAS Blue, CHAS Orange, MG and PG cardholders   
 
2.13 Besides subsidies for care at CHAS clinics, CHAS, MG  and PG cardholders enjoy 
subsidised referrals to public Specialist Outpatient Clinics (SOCs), as well as 
subsidised referrals to the National Dental Centre Singapore and National 
University Centre for Oral Health Singapore, if required.  
 
2.14 For patients with  chronic conditions, CHAS complements the Chronic Disease 
Management Programme (CDMP), which allows for MediSave to be used for 
outpatient treatment (for the same set of chronic conditions) covered under 
CHAS. Besides enjoying CHAS subsidies for the treatm ent of their chronic 
conditions, patients can also tap on their MediSave to defray part of the cost of 
these treatments.  
 
2.15 Patients who seek treatment for their chronic conditions at CHAS GP clinics can 
also receive subsidised rates for healthcare services  such as Diabetic Foot 
Screening (DFS), Diabetic Retinal Photography (DRP) and nurse counselling at 
Community Health Centres (CHCs) and Primary Care Network (PCN) clinics.  
 
2.16 The colour of the CHAS card indicates the subsidy tier that cardholders are 
entitle d to, namely the CHAS Blue, Orange or Green tier. All Pioneer Generation 
(PG) and Merdeka Generation (MG) seniors also receive special subsidies at 
CHAS clinics.


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All Pioneer Generation 
(PG) and Merdeka Generation (MG) seniors also receive special subsidies at 
CHAS clinics.  
 


Health Insurance   
 
172 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] 2.17 The amount that cardholders pay will be based on the fees charged by the clinic, 
minus the CHAS subsidies. The fees will vary according to each patient’s 
condition and clinic’s charges.  
 
2.18 Subsidies are also given to long -term care providers  which  provide healthcare 
services, such as renal dialysis, mental rehabilitation and  nursing home care. 
MOH provides subsidies of up to 80% depending on the type of intermediate 
long -term care service required . 
 
 
3. MEDISAVE   
 
3.1 MediSave  is a mandatory national individual health savings scheme in 
Singapore under the  Central Provident Fund  (CPF) umbrella. Between 8% and 
10.5% of each CPF member’s monthly salary (depending on his age) is set aside 
in his personal MediSave Account (MA). This amount consists of contributio ns 
from him and his employer.7 In the case of self -employed  persons, they must 
make compulsory contributions to their MediSave Accounts after receiving a 
Notice of Computation (NOC) of CPF contributions from IRAS. The MediSave 
contribution is computed bas ed on the self -employed person’s age and Net 
Trade Income (NTI). The Government also provides MediSave top -ups for 
Singaporeans, especially lower -income workers and elderly persons.   
 
3.2 Amounts in the MA earn an attractive annual interest income , with additional 
interest accruing to older CPF members to protect  their savings against 
inflation.  Since its introduction on 1 April 1984, MediSave has helped many 
Singaporeans to save for their medical needs. Saving for future medical 
expenses is important, since the need for medical care and hospitalisation 
increases significantly as one grows older.  
 
3.3 Starting 1 January 2022, the maximum amount members can top up to 
MediSave will be the difference between their Basic Healthcare Sum (BHS) and 
their current MediSave balances. Members were previously only able to 
contribute the lower of the CPF Annual Limi t and the difference between the 
BHS and their current MediSave balance. With the simplification, there is no 
longer a need to consider the CPF Annual Limit, which is typically made known 
only at the end of each year.  
 
3.4 Furthermore, with effect from 1 Janua ry 2022, members can enjoy annual tax 
relief of:  
▪ up to $8,000 (previously $7,000) when the member tops up to his/her own 
Special/Retirement Account and/or MediSave Account; and  
▪ an additional tax relief of up to $8,000 (previously $7,000) when the member 
tops up his/her loved ones’ Special/Retirement Account and/or MediSave 
Account  
 
7 Self-employed persons are also required to make contributions of between 4% an d 10.5% of yearly 
income. These rates only apply the first $6,000/month of each CPF Member’s monthly wage; in other 
words, the maximum contribution per month is 10.5% of $6,000, which is $650.


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9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         173  
Note that the changes related to top -ups to MediSave account s do not apply to 
self-employed persons.  
 
3.5 With the  Medisave Grant for Newborns , each Singaporean baby is now a CPF 
member at birth. The grant ensures that  newborns have enough to pay for their 
MeidiShi eld Life premiums from birth till age 21.  
 
A. Basic Healthcare Sum  
 
3.6 Contributions  to the MA are subject to a maximum amount, known as the Basic 
Healthcare Sum (BHS). The BHS is designed to be enough for a CPF member’s 
basic, subsidised healthcare needs in hi s old age. Hence, amounts in the MA up 
to the BHS cannot be withdrawn as cash.  
 
3.7 Amounts above the BHS will flow to the CPF member’s Special or Retirement 
Accounts to boost his monthly payouts. If the CPF member has already met his 
Full Retirement Sum, the amounts will flow to his Ordinary Account, and can 
be withdrawn as cash from the  age of 55 years.  
 
3.8 For CPF members aged below 65 in 2022,  the prevailing BHS is $66,000, and 
will be adjusted yearly. For CPF members who turn 65 in 2022, the cohort BHS 
is $66,000 and it will remain fixed for the rest of their lives. As life expectancy 
and healthcare costs rise, successive cohorts of CPF members  will need more 
MediSave savings for their healthcare expenses in their old age. Therefore, the 
BHS is adjusted yearly in January, to keep pace with the growth in MediSave 
use by the elderly. Refer to the following link at the CPF Website for the current 
BHS:https://www.cpf.gov.sg/member/faq/healthcare -financing/basic -
healthcare -sum/what -is-the-basic -healthcare -sum 
3.9 The yearly BHS adjustment will apply only to CPF members aged 65 years and 
below in that year. When a CPF member reaches the age of 65 years, th e BHS 
for him will be fixed at the prevailing BHS, and the amount will not change for 
the rest of his life8. 
 
B. Uses Of MediSave  
 
3.10 MediSave can be used to pay for:  
(a) the CPF member’s medical expenses at all accredited institutions, in both 
the public and private sector; and  
(b) medical expenses of the CPF member’s approved dependents, namely his 
spouse, children, parents, siblings, and grandparents. If paying for a siblin g 
or grandparent, the patient must be a Singapore Citizen or Singapore 
Permanent Resident (SPR).  
 
3.11 Let us now look at these uses of Medi Save in greater detail . 
 
 
 
 
8 All cohorts aged 65 years and above in 2016 will have the sa me BHS of S$49,800 for the rest of their 
lives.  


Health Insurance   
 
174 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] B1.  Outpatient Treatments  
 
3.12 MediSave  can be used to pay for selected outpatient services, including chronic 
disease treatments and preventative care at GPs, polyclinics and Specialist 
Outpatient Clinics (SOCs).  
 
(a) Outpatient Treatment For Approved Chronic Diseases Under The 
Chronic Disease Management Programme  
(i) MediSave can be used to pay for outpatient treatment for 23 
approved chronic conditions under the Chronic Disease 
Management Programme (CDMP) – metabolic conditions, mental 
health conditions, respiratory conditions and other c onditions such 
as Parkinson’s disease, dementia, epilepsy and osteoporosis.  The 
full list of approved chronic conditions  under the CDMP is available 
on the MOH Website at the following link: 
https://www.moh.gov.sg/policies -and-legislation/chronic -disease -
management -programme -(cdmp)  
(ii) These are chronic conditions  which can:  
▪ result in serious complications like heart disease, kidney failure 
and leg amputations, when not well managed; and  
▪ have high cost of treating the condition over the long term if 
poorly controlled.  
(iii) The aim of allowing MediSave use under the CDMP is to:  
▪ lower long -term healthcare costs; and  
▪ improve care for patients with chronic conditions , resulting in 
better health outcomes.


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(iii) The aim of allowing MediSave use under the CDMP is to:  
▪ lower long -term healthcare costs; and  
▪ improve care for patients with chronic conditions , resulting in 
better health outcomes.  
(iv) A CPF member can use up to $500 for non -complex chronic 
conditions, or $700 for complex chronic conditions per patient  per 
year, under the MediSave500/700 scheme . To ensure prudent use of 
MediSave  and to avoid overconsumption of medical services, 
patients must make a 15% cash co -payment for all CDMP claims.   
 
(b) Outpatient Treatment for Vaccinations  
MediSave500/700 can be used to pay for vaccinations under the National 
Childhood Immunisation Schedul e (NCIS) and National Adult 
Immunisation Schedule (NAIS). For the list of vaccinations which are 
payable by MediSave, please visit the CPF website at 
https://www.cpf.gov.sg/member/healthcare -financing/using -your -
medisave -savings/using -medisave -for-outpatient -treatments   
 
(c) Outpatient Treatment for Health Screenings  
The MediSave500/700 scheme can also be used to pay for recommended 
health screenings. MediSave -eligible health screenings include:  
▪ Mammogram screenings (for women aged 50 and above)  
▪ Selected screening tests for newborns  
 
 

9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         175  
(d) Flexi -MediSave for the Elderly  
Under the Flexi -MediSave scheme, patients aged 60 and above can use 
up to $ 300 per patient per year from their own or their spouse’s 
MediSave  Account for outpatient medical treatment, as well as approved 
vaccinations and screenings. Both should be aged 60 and above for the 
patient to tap on the spouse’s MediSave Account.    
 
Flexi -MediSave can be used at:  
▪ Specialist Outpatient Clinics in the pub lic hospitals and national 
specialty centres;  
▪ Polyclinics; and  
▪ Participating Community Health Assist Scheme (CHAS) Medical GP 
clinics.  
 
Flexi -MediSave can be used together with other outpatient MediSave  
limits, such as the MediSave500/700 limit.  
 
B2.  Inpatient Treatment s  
 
3.13 There are several types of hospitalisation and day surgery expenses that can be 
paid with MediSav e. 
 
3.14 The inpatient daily hospital limit applies if the patient is admitted to the hospital 
for at least 8 hours, while the day surgery limit applies if a patient undergoes a 
surgical operation listed under the Table of Surgical Procedures (TOSP) and is 
admitted and discharged within the same day . Visit the website:  
https://www.cpf.gov.sg/member/healthcare -financing/using -your -medisave -
savings/using -medisave -for-hospitalisation  to view the TOSP for the full lis t of 
surgeries and their MediSave withdrawal limits.  
 
3.15 Let us look at some of these items:  
 
(a) Inpatient  Episodes  
The CPF member can use up to $550 per day for the first two days and 
$400 per day thereafter under the daily hospital limit, which includes 
daily ward charges, daily treatment fees, investigations, and medicines.  
 
MediSave can also be used to pay for surg ical procedures required 
during the inpatient stay. The withdrawal limit depends on the 
complexity of the surgery, and ranges from S$250 to S$7,550 (refer to 
the MOH and the CPF Board websites for details).  
 
For a CPF member who passes away during his hosp italisation, the 
patient’s own MediSave can be used to pay for the last inpatient hospital 
bill in full, without being subject to existing MediSave withdrawal limits. 
This is because the need to save for future healthcare needs is no longer 
relevant follow ing his death.  
 
 
 


Health Insurance   
 
176 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] (b) Inpatient Psychiatric Episodes  
Up to $150 per day can be used from the MediSave account for daily 
hospital charges, subject to a maximum of $5,000 a year.  
 
(c) Day Surgery  Episodes  
The CPF member can use up to $300 per day for hospital charges, which 
include daily ward charges, daily treatment fees, investigations, and 
medicines.  
 
MediSave can also be used to pay for the day surgical procedure.


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MediSave can also be used to pay for the day surgical procedure. The 
withdrawal limit depends on the co mplexity of the surgery, and ranges 
from S$250 to S$7,550 (refer to the MOH and the CPF Board websites for 
details).  
 
(d) Assisted Conception Procedure s 
MediSave may be used for Assisted Conception Procedure  cycles 
regardless of whether treatment is received in inpatient or outpatient 
setting. Only the patient’s and her spouse’s MediSave accounts may be 
used.   
 
B3.  Long -Term Care  
(a) Rehabilitation  
MediSave  can be used to cover the costs of rehabilitative care, if the 
patient is:  
▪ An inpatient at an approved community hospital (for $250 per day, up 
to $5,000 per annum)   
▪ An inpatient at an approved convalescent hospital (for $50 per day, up 
to $3,000 per annum)  
▪ An outpatient at a day rehabilitation centre (for $25 per day, up to 
$1,500 per annum)  
▪ An outpatient at an approved day hospital (for $150 per day, up to 
$3,000 per annum)  
(b) Palliative Care  
MediSave can be used to pay for palliative care, subject to t he following 
withdrawal limits:  
▪ Approved inpatient hospice palliative care services (up to $250 per 
day for general palliative care, and up to $350 per day for specialised 
palliative care)  
▪ Home palliative and day hospice care (up to $2,500 per lifetime). If 
the patient has terminal cancer, end -stage organ failure or advanced 
dementia, there will not be any withdrawal limit if the bill is paid 
using the patient’s own MediSave.  
(c) Disability Care  
Under MediSave Care, severely disabled Singapore Residents aged 30 
and above will be able to withdraw up to $200 per month in cash from 
their or their spouse’s MediSave account for their long -term care needs. 
The withdrawal quantum depends on the MediSave balance at the point 
of monthly withdrawal  (see Appendix 9A ).   
 

9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         177  
B4.  Insurance Premiums  
 
3.16 Besides using MediSave to pay for medical expenses, a CPF member can use 
his MediSave  to pay for his own health insurance premiums, or those of his 
approved dependents. MediShield Life and ElderShield or CareShield Life 
premiums can be paid fully with MediSave  whereas Integrated Shield Plans  
(IPs) and ElderShield or CareShield Life supplem ent premiums are subject to 
withdrawal limits which are periodically reviewed by MOH.  
 
3.17 Table 9.1  summarises the uses of the MediSave Account.  
 
Table 9.1 The Uses of MediSave Account  
Uses of Medisave  Items  that can be paid using MediSave  
Outpatient Treatments  Selected outpatient treatments such as:  
▪ Approved chronic conditions under the 
CDMP  
▪ Vaccinations  
▪ Health screenings  
Inpatient Treatments  Inpatient care such as:  
▪ Inpatient episodes  
▪ Inpatient psychiatric episodes  
▪ Day surgery episodes  
▪ Assisted Conception Procedures  
Long -Term Care  Long -Term Care treatments which include:  
▪ Rehabilitative care  
▪ Palliative care  
▪ Disability care  
Insurance Premiums  Premium payments of:  
▪ MediShield Life  
▪ ElderShield /CareShield Life  
which can be fully paid with MediSave  
▪ Integrated Shield Plans and 
ElderShield /CareShield  Life 
supplement s 
which are subject to withdrawal limits  
periodically reviewed by MOH  
 
C. How Much Medisave Can Be Used?  
 
3.18 The use of MediSave  is subject to withdrawal limits and other conditions. The 
types of limits include:  
(i) Withdrawal Limit – the maximum amount that the CPF member can 
withdraw from his/her MediSave Account for his or her medical expenses . 
For the different categories and amount of withdrawal limits which apply to  
a  member’s CPF account, please refer to Appendix 9A . 
(ii) Additional Withdrawal Limit (AWL)  – the maximum amount of MediSave 
that can be used to pay for additional private insurance c overage. The 
excess premiums above AWLs are payable in cash.


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(ii) Additional Withdrawal Limit (AWL)  – the maximum amount of MediSave 
that can be used to pay for additional private insurance c overage. The 
excess premiums above AWLs are payable in cash.  Please refer to 

Health Insurance   
 
178 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] Appendix 9A for the AWL for Integrated Shield Plans  (IP) and 
ElderShield/CareShield Life supplements.  
 
C1. Where Can MediSave  Be Used?  
 
3.19 Payments  via MediSave  are a llowed in all public healthcare institutions, as well 
as approved private hospitals and medical institutions. For an updated list of 
medical institutions participating in MediSave , refer to the CPF Board Website.  
 
C2. Whose MediSave  Can Be Used?  
 
3.20 All CPF members are allowed to pay for their approved dependents’ medical 
expenses; and there may be more than one payer per bill, e.g. two children can 
pay for their mother’s hospitalisation bill. Each CPF member should specify to 
the institution the amount of MediSave that he would like to use to pay for the 
hospitalisation bill.  
 
3.21 If the immediate  family members’ MediSave  are not sufficient to pay for the 
hospitalisation bill, then the patient’s family members can make an appeal to 
the hospital to have the bill settled by non -immediate family members via 
MediSave, e.g. children -in-law. However, this option is available only if the 
patient meets certain conditions, such as having stayed in the Class B2 or Class 
C ward of a public hospital.  
 
C3. Prudent Use of MediSave  
 
3.22 MediSave  use is subject to withdrawal limits, which are generally sufficient for 
subsidised treatments in public healthcare institutions. This ensures that there 
continues to be sufficient savings for future healthcare needs. Those seeking 
treatments in Class B1 a nd Class A wards of public hospitals or private hospitals 
will usually have some cash out -of-pocket payments.  
 
C4. Distribution Of MediSave  Upon Demise  
 
3.23 If a patient was hospitalised just before death and had authorised the use of his 
MediSave to pay for his medical bill, his MediSave balance would be used in 
full, without being subject to the existing MediSave withdrawal limits, to pay 
for his last inpatient medical bill.  
 
3.24 If the patient had not authorised the use of his MediSave before his demise, his 
immediate family member (spouse, parent, or child who is aged 21 years and 
above), or donee or deputy can also do so for the last inpatient medical bill, 
provided that it has not been paid out to the patient’s nominated beneficiaries. 
In the event that the patient does not have any immediate family member, or 
donee or deputy to authorise the use of the patient’s MediSave, a relative who 
has been taking care of the patient may a lso write to MOH through the hospital 
to seek approval for the relative to authorise the withdrawal of patient’s 
MediSave, to pay for the last inpatient medical bill.  
 

9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         179  
3.25 The remaining MediSave  balance, after the payment of the last medical bill, 
would be distributed to the nominated beneficiaries of the patient’s CPF account 
if a nomination was made before his death. If there was no nomination made, 
the balance in the deceased patient’s MA would be distributed by the Public 
Trustee to his family members un der the intestacy laws for non -Muslims, or the 
Muslim inheritance law for Muslims.  
 
 
4. MEDISHIELD LIFE  
 
4.1 Unlike MediSave which is a savings scheme, MediShield Life is a basic health 
insurance scheme that protects all Singapore Citizens (SCs) and Permanent 
Residents (PRs) against large medical bills for life, regardless of age or health 
conditions. The claim limits are sized to cover subsidised bills incurred for 
hospitalisation in class B2/C wards, day surgery, and selected costly outpatient 
treatments (e.g ., dialysis and chemotherapy) in the public hospitals.   
 
4.2 There is no need to apply for MediShield Life. All SCs and PRs are automatically 
covered under MediShield Life from 1 Nov 2015. New SCs are covered from 
birth or from the day they attain citizenship. PRs are covered from the day they 
attain permanent residency.


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New SCs are covered from 
birth or from the day they attain citizenship. PRs are covered from the day they 
attain permanent residency.  
 
4.3 By risk -pooling across the entire population, MediShield Life provides universal 
coverage for all Residents for life. MediShield Life premiums may be fully paid 
from MediSave.  
 
4.4 MOH  regularly reviews and enhances MediShield Life to ensure coverage  
adequacy and premium affordability. No one will lose MediShield Life coverage 
due to  an inability to pay premiums.  
 
4.5 MediShield Life provides coverage for all ward classes  including private 
hospitals. However, MediShield Life benefits are designed based on Class B2/C 
bills, so as to keep premiums affordable . Those who would like additional  
coverage in Class A/B1 wards or private hospitals may consider buying 
Integrated Shield Plans (IP). As IPs premiums are higher than MediShield Life 
premiums and increase with age, one should consider the affordability of 
premiums over the longer -term  prior to purchase.  
 
A. MediShield Life Premiums  
 
4.6 MediShield Life premiums are actuarially priced based on the health risks and 
expected healthcare utilisation of each age group so that each age group’s 
payouts are broadly supported by their own premiums. This ensures that 
MediShield Life remains sustaina ble even as our population ages. Any 
applicable subsidies are automatically applied to the premium before premium 
payment.  
 
4.7 Those with pre -existing medical conditions can enjoy coverage for their 
conditions. Only those with serious pre -existing medical con ditions listed in the 
MOH website need to pay a nominal Additional Premium of 30% for the first 10 


Health Insurance   
 
180 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] years, in addition to the standard MediShield Life premiums.  
 
4.8 MediShield Life premiums can be fully paid by Medisave. One can pay 
premiums from own MediSave , or family members may pay one’s premium 
using their MediSave. Parents may also tap on the MediSave Grant for 
newborns to pay for their child’s MediShield Life premiums.  
 
B. MediShield Life Subsidies  
 
4.9 The Government provides various premium subsidies and su pport measures to 
help SCs and PRs with their MediShield Life premiums, including those who 
need to pay Additional Premiums:  
(a) Premium Subsidies for the lower - to middle - income;  
(b) Pioneer and Merdeka Generation Subsidies for Pioneer and Merdeka 
Generation seniors;  
(c) COVID -19 Subsidies for SCs; and  
(d) Additional Premium Support for those who are unable to afford their 
premiums even after subsidies, MediSave use and have limited family 
support.  
 
B1. Premium Subsidies for the lower - to middle - income  
 
4.10 This is a  permanent feature, available to lower - to middle - income families with 
household monthly income per person of S$2, 800 and below, and  living in 
homes with an Annual Value (AV) of S$21,000 and below. The S$21,000 AV 
threshold covers all HDB flats and a small number of private properties. Those 
who own more than one property will not be eligible for this subsidy.  
 
4.11 Those eligible can recei ve subsidies of up to 50% of their premiums. PRs will 
receive half the subsidy applicable to SCs.  
 
B2. Pioneer Generation Subsidies and MediSave top -ups    
 
4.12 Pioneers refer to Singapore Citizens born on or before 31 December 1949 and 
obtained citizenship on or before 31 December 1986.  
 
4.13 Pioneers receive special Pioneer Generation Subsidies of between 40 -60% 
depending on age. This is regardless of their household monthly income or the 
Annual Value of their home.  
 
4.14 Pioneers also receive $250 - $900  a year in MediSave top -ups (depending on 
year of birth) for life, which can be used to pay for their MediShield Life 
premiums.  
 
4.15 Older Pioneer Generation Seniors who have serious pre -existing conditions 
also receive additional MediSave top -ups of $50  - $200 annually from 2021 to 
2025, which can be used to pay for their MediShield Life premiums.   
 
 

9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         181  
B3.


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9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         181  
B3. Merdeka Generation Subsidies an d MediSave top -ups    
 
4.16 Merdeka Generation seniors refer to:  
(i) living Singapore Citizens who were born from 1 January 1950 to 31 
December 1959 and had obtained citizenship on or before 31 December 
1996; and  
(ii) those who were born on or before 31 December 1949, had obtained 
citizenship on or before 31 December 1996 and do not receive the Pioneer 
Generation Package.  
 
4.17 From 1 July 2019, Merdeka Generation seniors receive additional Merdeka 
Generation Subsidies of 5% of their annual MediShield Life premiums, 
increasing to 10% after they turn 75 years old, regardless of their household 
monthly income or the Annual Value of their home. This is on top of the above 
Premium Subsidies that the seniors may receive.  
 
4.18 Merdeka Generation members will also receive $200 a  year in MediSave top -
ups for five years from 2019 to 2023. These top -ups can be used to pay for their 
MediShield Life premiums.  
 
B4. COVID -19 Subsidies  
 
4.19 COVID -19 Subsidies are provided to all Singapore Citizens for two years after 
the increase in MediShield Life premiums on 1 Mar 2021.  
 
4.20 It is applied on the net premium increase over MediShield Life premiums before 
1 Mar 2021, after Premium Subsidies, Pioneer Generation Subsidies or Merdeka 
Generation Subsidies, where applicable. It covers 70% of the net premium 
increase in the first year, followed by 30% of the net premium increase in the 
second year.  
 
B5.  Additional Premium Support  
 
4.21 Indiv iduals who are unable to afford MediShield Life premiums after 
Government subsidies, MediSave use and have limited family support will be 
invited by the Government to apply for Additional Premium Support (APS). If 
approved, APS will cover the outstanding M ediShield Life premiums (if any) as 
well as the premiums for the next two years.  
 
C. MediShield Life Benefits  
 
4.22 MediShield Life benefits are reviewed regularly to keep pace with the evolving 
healthcare landscape and cost inflation so that it remains sustainable and 
relevant to the needs of Singaporeans. Appendix 9B shows the MediShield Life 
benefits applicable for a dmissions or treatments received on or after 1 March 
2021.  
 
  

Health Insurance   
 
182 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] D. How Are MediShield Life Claim Payouts Computed?  
 
4.23 The MediShield Life Scheme pays on a reimbursement basis, subject to the 
claim limits  imposed on the covered medical expenses, as well as deductible, 
co-insurance and pro -ration factors.  
 
4.24 The deductible  is the fixed amount payable by the insured each policy year (the 
year following his policy renewal month), before  the MediShield Life payout 
starts. The deductible is payable only once every policy year. It helps to sieve 
out smaller, more affordable bills, which can be paid using MediSave and/or 
cash, and helps to keep the premiums affordable by focusing MediShield Life 
payouts on larger bills where support is more critical.  
 
4.25 Co-insurance  is the patient’s share of the claimable amount which the insured 
will have to pay, along with the deductible. It decreases from 10% to 3% as the 
bill size increases. Co -insurance h elps to prevent over -consumption of medical 
services and over -servicing by healthcare providers.  
 
4.26 As private hospital bills and Class A/B1 bills in public hospitals are generally 
higher than the Class B2/C bills that MediShield Life is designed for, they are 
pro-rated to the equivalent level of a Class B2/C bill before MediShield Life 
payouts are computed. This ensures comparable payouts for subsidised and 
private patients.  
 
4.27 Table 9.2 shows an example of  how the reimbursement under MediShield Life 
is arrived at.  
 
  

9.


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This ensures comparable payouts for subsidised and 
private patients.  
 
4.27 Table 9.2 shows an example of  how the reimbursement under MediShield Life 
is arrived at.  
 
  

9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         183  
Table 9.2: Claim Computation Of MediShield Life For Singapore Citizen 
Hospitalised In Class A Ward  
 
Claim computation for a Singapore Citizen aged 60 who stays in a Class A ward  
Length of Stay: 18 Days  
Procedure Performed: Hip Replacement  
Pro-ration Factor based on ward class 35%  
 
 Hospital Bill  35% of Hospital 
Bill9 
(Refer to Table H)  MediShield 
Life 
Claim  
Computation  
Daily Ward & 
Treatment Charges 
(18 days normal 
ward)  $12,000  $4,200  
($12,000 x 35%)  $4,20010 
Surgical Procedure 
(Table 5C)  $8,500  $2,975  
($8,500 x 35%)  $2,18011 
Implant  $4,000  $1,400  
($4,000 x 35%)  $1,40012 
Total  $24,500  $8,575  $7,780  
Less Deductible13 - - ($2,000)  
Claimable Amount  
(less Deductible)  - - $5,780  
Less Co -insurance  - - ($439)14 
Medishield Life pays  - - $5,341  
MediSave and/or 
Cash  - - $19,159  
 
4.28 Note from Table 9.2 that MediShield Life does not cover the majority of the  
Class A ward  hospital bills. The insured’s hospital bill was pro -rated to the 
equivalent Class B2/C bill, before being subject to the claim limits. He may use 
his MediSave  (subject to the MediSave  limits, based on the number of days 
stayed in hospital and the surgical table relating to his surgical  procedure) 
and/or cash to pay the remaining portion of his bill (S$ 19,159 ).  
 
4.29 Therefore, it is important for the insured to consider his insurance coverage  
carefully , before  he chooses the hospital or ward to which he wishes to be 
admitted. If he wishes to have coverage for Class A/B1 ward and private hospital 
stays, he may apply to any of the approved insurers for an IP. 
 
 
 
9 As the insured member stayed in Class A ward, the MediShield Life claim is computed based on 35% of 
the bill  
10 Lower of the claim limit in Table A for Daily Ward & Treatment Charges, ($700 x 18 days) = $12,600, on 
35% of charges incurred of $12,000 = $4,200. Therefore, the claimable amount is $4,200.  
11 Lower of the claim limit in Table A for surgical procedure, $2,180 (Table 5C), or 35% of charges incurred 
of $8,500 = $2,975. Therefore, the claimable amo unt is $2,180.  
12 Lower of the claim limit in Table A for Daily Ward & Treatment Charges, ($1000 x 2 + $800 x 16 days) = 
$14,800, on 35% of charges incurred of $12,000 = $4,200. Therefore, the claimable amount is $4,200.  
13 The insured member is below 80 yea rs old, subject to deductible of $2,000 for Class A ward.  
14 Co-insurance = ($3,000 x 10%) + ($2,780 x 5%) = $439.  

Health Insurance   
 
184 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] 4.30 Exclusions are imposed on certain medical treatments and expenses. For such 
expenses incurred, the insured will not be able to claim under his MediShield 
Life.


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For such 
expenses incurred, the insured will not be able to claim under his MediShield 
Life. 
 
4.31 The following treatment items, procedures, conditions, activities are not 
covered by MediShield Life and cannot be claimed (Applicable fo r admissions 
or treatments received on or after 1 March 2021):  
▪ Treatment for any contraceptive operation or procedure, infertility, sub -
fertility, or assisted conception or sex re -assignment surgery  
▪ Surgical interventions for the following conditions: Tris omy 13, Bilateral 
Renal Agenesis, Bart’s Hydrops and Anecephaly  
▪ Cosmetic surgery  
▪ Dental work or dental treatment, except approved dental treatment  
▪ Outright purchase of kidney dialysis machines, iron -lung and other special 
appliances  
▪ Optional items such as television, telephone, special requested meals and 
other items which are not necessary for the treatment of any illness, 
condition or any injury or disability  
▪ Private nursing charges  
▪ Ambulance services  
▪ Vaccination  
▪ Treatment for injuries and disablement res ulting from deliberate exposure 
by the insured to exception danger (except in an attempt to save human 
life) 
▪ Treatment for injuries and disablement resulting from insured person’s 
own criminal act  
▪ Treatment of injuries arising directly or indirectly from n uclear fallout, war 
and related risk  
▪ Treatment of injuries arising from direct participation in civil commotion, 
riot or strike  
▪ Expenses incurred after the 7th calendar day from being certified to be 
medically fit for discharge from inpatient treatment and  assessed to have 
a feasible discharge option by a medical practitioner  
▪ Overseas medical treatment  
▪ Treatment which has received reimbursement from Workmen’s 
Compensation and other forms of insurance coverage  
▪ Treatment for pregnancy, childbirth (including Caesarean operations) or 
abortions, except treatments for serious complications related to 
pregnancy and childbirth  
  

9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         185  
E. MediShield Life Fund  
 
4.32 The MediShield Life Scheme is a not -for-profit scheme. All premiums collected 
are placed in the MediShield Life Fund and are used solely for the benefit of 
policyholders and in the administration of the scheme. The financial accounts 
for the Fund are audited by an external auditor and submitted to Parliament 
every year.  
 
 
5. INTEGRATED SHIELD PLANS (IPs)  
 
5.1 Integrated Shield Plans (IPs) are MediSave -approved hospitalisation insurance 
plans made up of two parts. The first is the MediShield Life component 
administered by the CPF Board. The second is an additional private insurance 
coverage componen t administered by approved private insurers, typically to 
cover Class A/B1 wards of public hospitals or private hospitals. Following the 
implementation of MediShield Life on 1 November 2015, MediShield Life 
automatically replaced the MediShield component o f IPs. Thus, those who have 
IPs are already covered by MediShield Life, and there is no duplication of 
coverage between IPs and MediShield Life.   
 
5.2 The following plans are IPs (as at 1 Apr 2021 ): AIA HealthShield Gold Max, 
Singlife with Aviva MyShield, AXA Shield, Great Eastern  SupremeHealth, 
Income Insurance Limited’s IncomeShield , Prudential’s PRUshield  and RHI 
Raffles Shield . To aid your understanding of the different IPs offered, you are 
advised to refer to  the updated compariso n tables of IPs across insurers, 
categorised by ward class, at the MOH Website15. 
 
5.3 The figure below illustrates  the components of Integrated Shield Plans (IPs) as 
outlined above.  
 
 
 
 
 
15 https://www.moh.gov.sg/cost -financing/healthcare -schemes -subsidies/medishield -life/comparison -of-
integrated -shield -plans  

Health Insurance   
 
186 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]  
 
With the different IPs available, it is necessary for the sellers of such plans to 
understand the different plans offered in the insurance market, and to advise 
their prospective clients, based on the needs and long -term affordability of 
each individual client’s position.  
 
(a) As part of due diligence, clients should  be informed of the key 
differences in premiums, benefits, exclusions, deductibles, co -insurance 
and other co -payment features between the various IPs offered by their 
insurer, versus MediShield Life.


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There are different benefits  provided in 
the IP policy,  and plans can be “as charged” or “non -as-charged” (i.e. 
they have sub -limits imposed). Information provided should be easy to 
understand, unambiguous and clearly explained to help clients make an 
informed decision.  
 
(b) Clients should consider if they would w ish to stay in a private or 
subsidised ward in a public hospital, or in a private hospital, and if they 
wish to choose their own doctors. To aid them in this decision, agents 
should explain to clients how a given plan’s coverage might differ 
according to t heir choice of ward, hospital, and doctor (e.g., in the case 
of panel providers).  Subsidised treatments in public hospitals (B2/C 
wards) currently make up two -thirds of all admissions from Singapore 
residents. For the vast majority of these treatments, Me diShield Life 
provides sufficient coverage, meaning that having an IP plan would not 
provide any additional payout. As such, members may not need to 
purchase an IP if they intend to stay in Class B2/C wards.  
 
(c) Premiums for IPs are higher than for MediShield Life. IP premiums 
increase significantly as an insured person gets older. Premiums for 
health insurance usually increase with age and are subject to change. 
The private insurance component of the IP premiums could be up to 4 
times the MediShield Life premiums for those in their 70s or 80s this 
year. Clients should consider if they can afford their IP premiums in the 
long term.  


9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         187  
(d) The additional private insurance component of IP premiums is payable 
by MediSave on ly up to the Additional Withdrawal Limit (AWL), which 
is often exceeded at older ages. The policyholders may have to pay a 
substantial portion of their IP premiums in cash, especially at the older 
ages.  
 
(e) Unlike MediShield Life which provides coverage for pre-existing medical 
conditions (with Additional Premiums for the first 10 years), the 
coverage for the private insurance component of the IP may be declined 
or imposed with exclusions for pre -existing conditions. The private 
insurance component may also h ave premium loading, arising from pre -
existing conditions. Clients should be advised to disclose their medical 
history truthfully and completely, to avoid unexpected policy exclusions 
subsequently. Once their policy has been approved, clients should be 
mad e to understand their full list of policy exclusions from their insurer 
or agent, and be advised of their free -look period where they can review 
their purchase and obtain a full refund of premiums if they choose to 
cancel their policy. Where possible, clie nts should be reminded again of 
their exclusions prior to any treatment, procedure or admission,  
including both general exclusions and specific medical exclusions of 
pre-existing conditions.  
 
A. Integrated Structure Of IPs  
 
5.4 Under the integrated structure of IPs, if a Singapore Citizen or Permanent 
Resident purchases an IP, he will enjoy the benefits of MediShield Life within 
his IP. However, he will be serviced by his private insurer. In other words, he 
will continue to pay o ne premium and needs to make only one claim with just 
his private insurer. His private insurer will then arrange with the CPF Board on 
the amount claimable under the MediShield Life component of the plan. The 
insured will not need to liaise with both parti es (i.e. his insurer and the CPF 
Board).  
 
A1. Coverage  
 
5.5 As mentioned above, a person insured with an IP already benefits from the 
MediShield Life component within his IP. He will have coverage for pre -existing 
conditions and be assured of lifelong coverage  under the MediShield Life 
component of his IP. This is so, even if the condition is excluded from the 
additional private insurance coverage by the IP insurer.  
 
5.6 Due to COVID -19, the seven authorised IP insurers have extended their 
coverage of hospitalisati on resulting from COVID -19 vaccine complications until 
Dec 31, 2022, as mentioned by the Life Insurance Association, Singapore (LIA 
Singapore) . The extended coverage will continue to apply to all IP  policyholders 
who received COVID -19 vaccines under the na tional vaccination programme, as 
well as those approved by the World Health Organisation (WHO) under its 
emergency use listing and administered in Singapore under the special access 
route.


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Health Insurance   
 
188 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] A2. Premiums & MediShield Life Subsidies  
 
5.7 The IP premiums paid to private insurers also comprise two parts, namely the 
premium for the MediShield Life component , and the premiums for the 
additional private insurance component. A person insured under an IP will also 
be able to receive the applicable MediShield Life subsidies (i.e. Premium 
Subsidies for lower - to middle -income; Pioneer and Merdeka Generation 
Subsidi es; Transitional Subsidies) if he meets the eligibility criteria, but will not 
be eligible for Additional Premium Support. Those who cannot afford to pay for 
IP premiums should remain on MediShield Life.  
 
5.8 When deciding on the level of premiums for the addi tional private insurance 
component, private insurers will also need to factor in claims experience and 
medical inflation along with the benefits offered. Clients concerned with the 
affordability of IP premiums should consider more affordable insurance opti ons 
if it is within their means, such as IPs with a lower ward entitlement, or consider 
whether MediShield Life (which provides sufficient coverage for the vast 
majority of subsidised treatments (B2/C wards) already adequately suits their 
needs.  
 
5.9 The main  differences between the MediShield Life Scheme and an IP are  
described in Table 9.3 below . 
 
Table 9.3: Differences Between MediShield Life & IP  
MediShield Life  Scheme  Integrated Shield Plan (IP)  
(a) It is administered by the CPF 
Board.  (a) It is administered by  private 
insurers, as approved by MOH.  
(b) Its coverage is sized for stays in 
Class  B2/C wards of public 
hospitals.  (b) It provides for enhanced coverage 
beyond MediShield Life, with 
various plan types available for 
stays in private hospitals and/or 
Class A/B1 wards of public 
hospitals.  
(c) It covers all pre -existing 
conditions.  (c) Coverage for the private insurance 
component of the IP may be 
declined or imposed with 
exclusions and/or premium 
loading , arising from pre -existing 
conditions.  
(d) There is no minimum or 
maximum age limit.  (d) It may have a minimum or 
maximum entry age limit.  
(e) There are sub -limits applicable.  (e) It may have sub -limits, although 
most do not have sub -limits.  
(f) MediShield Life premiums are 
fully payable by MediSave . (f) MediShield Life component of the 
IP is fully payable by MediSave , 
while private insurance 
component of the IP is payable by 
MediSave  up to Additional 
Withdrawal Limit, and the 
remainder is payable by cash.  

9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         189  
(g) All Singapore Citizens and 
Permanent Residents ar e 
automatically covered for life. 
No application is required.  (g) Application to private insurers is 
required.  
 
B. Standard IP  
 
5.10 The Government has worked with IP insurers to develop the Standard IP, a “no 
frills” product targeted at covering large Class B1 ward hospital bills and 
selected outpatient treatments.  
 
5.11 From 1 May 2016, all IP insurers were  required to sell the Standard I P. The 
benefits of the Standard IP are regulated by MOH and  are identical across all IP 
insurers. The Standard IP has claim limits sized to fully cover nine out of ten 
Class B1 bills. Like other IPs, it also has co -insurance and deductible 
components.  
 
5.12 As a private plan that provides coverage beyond MediShield Li fe, the Standard 
IP is managed by insurers. Like all other IPs, premiums and underwriting 
decisions for the plan are determined by each insurer, based on their own 
commercial considerations and risk assessment frameworks. Therefore, 
premiums vary, dependin g on each insurer’s approach.  
 
5.13 Nonetheless, the Standard IP is an affordable option for Singapore Citizens and 
Permanent Residents who want additional coverage beyond MediShield Life 
and may find other higher coverage IPs too expensive. It is also a viable  option 
for those who want to switch from their Class A and Private Hospital IPs to a 
more affordable plan.  
 
C. MediSave  Use For IP Premiums  
 
5.14 MediSave  can be used to pay premiums for IPs, either in full or in part, 
depending on the age group and the IP plan type.


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C. MediSave  Use For IP Premiums  
 
5.14 MediSave  can be used to pay premiums for IPs, either in full or in part, 
depending on the age group and the IP plan type. The MediShield Life 
component of the IP premiums is fully payable by MediSave . This takes into 
account any Additional Premiums (for those with serious pre -existing 
conditions) and MediShield Life subsidies (where applicable). From 1 
November 2015, MediSave  use for the additional private insurance component 
of the IP premiums is subject to the new Additional Withdrawal Limit (AWL). 
The AWL is set per insured person per policy year, as  stated below : 
(a) Age Next Birthday (ANB) 40 years and below: S$300  
(b) ANB 41 to 70 years: S$600  
(c) ANB 71 years and above: S$900  
 
 
 
 
 
 
 

Health Insurance   
 
190 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] D. Riders  
 
5.15 IP insurers  also sell rider plans, which pay for the co -insurance and deductible 
portion of the IP,  and may make  cash payouts upon hospitalisation. These riders 
are not approved  for MediSave  use, and  insurers are not allowed to market 
riders as part of IPs. Sellers o f such riders  should highlight the distinction 
between IPs and riders to policyholders and  share that riders can be paid using 
only cash. Importantly, they should remind policyholders that rider premiums 
rise significantly with age. Instead of paying for a  rider, the deductible and co -
insurance portion incurred in the event of hospitalisation can be saved for and 
paid via MediSave  or cash.  
 
5.16 On 8 March 2018, MOH introduced requirements for new IP riders to have :  
(a) a co-payment of 5% or more, to encourage prudent use and appropriate 
charging of healthcare services, and  
(b) a co -payment cap for panel/pre -authorised treatment to protect 
policyholders against the unlikely event of large bills. Insurers can set the 
cap at $3,000 or more per policy yea r.  
 
5.17 These requirements apply to new policyholders who purchase riders on and 
after 8 March 2018.  
 
D1. The Principle Underlying The Need For Co -Payments16 
 
5.18 Co-payment is an important principle in the design of healthcare insurance. It 
encourages policyholders and their doctors, to consider the necessity of the 
medical treatment and its cost, so that they can make an informed decision on 
the appropriate healthcare services.   This encourages prudence and keeps 
healthcare cost, and health insurance p remiums, affordable and sustainable in 
the long term.   
 
5.19 This principle applies regardless of hospital category.   Integrated Shield Plan 
(IP) full riders that covered the entire co -payment under the IPs were not in line 
with this principle.   Such riders all owed policyholders to avoid co -payment 
regardless of their bill size, and had contributed to over -consumption, over -
servicing and over -charging.    
 
5.20 This was one of the reasons why MOH had announced the requirement for a 
minimum 5% co -payment for new riders  across all settings in March 2018.   This 
applied for new riders sold from 1 April 2019, while riders sold after the 
announcement, between 8 March 2018 and 31 March 2019, had to transition 
onto these new co -payment riders by 1 April 2021.   
 
5.21 While this co -payment requirement was not mandated for riders purchased 
before 8 March 2018, some insurers announced  that they will also be including 
a co -payment component to these riders.   This is allowed under their 
 
16 Partially extrac ted and adapted from https://www.moh.gov.sg/news -highlights/details/co -payment -in-
integrated -shield -plans -for-specific -hospital -categories -and-breakdown -of-average -claims -made -through -
full-riders -of-integrated -shield -plans  

9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         191  
contractual terms with their policyholders.   MOH has encouraged the insurers, 
in considering these changes, to ensure that their policyholders’ interests are 
safeguarded even as insurers seek to ensure the sustainability of their 
portfolios.


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MOH has encouraged the insurers, 
in considering these changes, to ensure that their policyholders’ interests are 
safeguarded even as insurers seek to ensure the sustainability of their 
portfolios. As an additional safeguard, insurers are re quired to clearly explain 
these changes to their policyholders at least 30 days before they take effect.   
 
5.22 To provide their policyholders more assurance after these changes, some 
insurers had also introduced co -payment limits for treatments that are provid ed 
by their panel doctors, or for pre -authorised treatments. However, even if 
policyholders do not seek treatment with a panel doctor or are unable to seek 
pre-authorisation prior to treatment, they can still claim under their IP and rider, 
though addition al benefits such as the co -payment limit may not apply. 
Policyholders can also continue to tap on MediSave to pay the co -payment 
amount under their riders, subject to the MediSave withdrawal limits.  
 
E. Terminating or Switching IP/Switching Insurer  
 
5.23 An IP  policyholder who cannot afford, or does not wish to continue paying the 
premium for his IP, can switch his plan to a lower coverage plan within the same 
insurer at any point in time, without additional underwriting involved. He can 
also  terminate his IP at any point in time, and still be covered by MediShield 
Life which provides basic health insurance, regardless of any pre -existing 
conditions.   
 
5.24 In the event that the person with an existing IP switches to a new IP with another 
insurer, his original IP with the previous insurer will be automatically 
terminated. Moreover, under the new IP with the new insurer, he will undergo 
underwriting again. As such, he may lose coverage for his existing medical 
conditions covered by his original plan  with his existin g insurer and  may not be 
able to re -apply for his original coverage subsequently.  
 
5.25 Any policyholder who switches his IP from one insurer to another will have the 
option to go back to the previous insurer within 30 days from the date of 
notification of termination given to  the previous insurer. No re -underwriting is 
allowed by the previou s insurer, and it would be as if the first IP had never been 
terminated.  
 
5.26 If a claim is received by the new insurer and the claim incurred date falls within 
30 days from the commencement date of the new policy and the new insurer is 
not able to admit the c laim for any reason, the new insurer has the option to 
request the policyholder to reinstate his policy with the previous insurer. The 
previous insurer will take the claim incurred date (or claim event date) to be the 
date of request to reinstate the polic y. Once reinstated, the claim will be 
assessed by the previous insurer, and the claim will be paid by the previous 
insurer if the liability under the previous insurer’s policy is established.   
 
  

Health Insurance   
 
192 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] F. Risk-Loading By Private Insurers  
 
5.27 With effect from the launch of MediShield Life, MOH allow s IP insurers to risk -
load insured members with pre -existing conditions for the private insurance 
component of the IPs . This will help to reduce uncertainty of coverage owing to 
exclusions, and afford  insured members who  prefer to pay higher private 
insurance premiums  the peace of mind, knowing that they are also covered for 
their pre -existing conditions by the private insurance component of their IPs. 
More details on this will be shared by private insurers if and when th ey decide 
to offer risk -loading to their insured members.  
 
G. Pre-Authorisation for IP, Claim Process For MediShield Life/IP, Other Private 
Insurance & MediSave  
 
5.28 The LIA has issued a guidance paper on Pre -Authorisation Process for IPs.  Pre-
authorisation is a service where the IP insurer gives prior approval to the 
hospitalisation and/or medical treatment and associated costs before the actual 
surgery or admission. It is designed for elective treatment in the private 
healthcare sector, for  patients (policyholders) seeking specialist care by private 
doctors in private hospitals.  
 
5.29 The benefits in having  pre-authorisation  are:  
(a)  Insurers can assess the medical necessity and cost of treatment to ensure 
it is within the terms and conditions of the policy’s coverage;  
(b)  Patients will have a peace of mind in know ing that their procedure is 
within their insurance coverage; and  
(c)  Healthcare providers have better clarity on the type of procedures covered 
by insurance to better advise their patients prior to the actual procedure.


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Policyholders are thus encouraged to seek pre -authorisation for planned 
procedures as far as possible if the option is provided by the insurer.  
 
5.30 All IP i nsurers offering pre -authorisation  services to its IP policyholders have to  
use the standard LIA Pre -Authorisation Form. (See Appendix 9C)  
 
5.31 IP insurers  will directly settle pre -authorised bill s with the hospital, day surgery 
centre or clinic.  
 
5.32 Any insured CPF member who wishes to claim from his MediShield Life, IP 
and/or MediSave  will need to complete the Medical Claims Authorisation Form 
to: 
(a)  allow the hospital to claim from his insurer; and  
(b)  instruct the CPF Board to deduct from his MA to pay for his hospital bill, 
while the insurer settles the claim, which may take some time. The patient 
may be required to pay a deposit in cash upon his hospital admission, as 
his MediSave  may not cover the full hospital charges. This is usually the 
case for non -subsidised ward classes.  
 

9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         193  
G1. Claiming From MediShield Life/IP & MediSave  
 
5.33 If there is no pre-authorisation , the insured CPF member under an IP can 
approach the hospital to trigger a request for a Letter of Guarantee (LOG) from 
his insurer  upon hospital admission . The LOG is a service provided by all IP 
insurers for insured members, to ease the admission process to the hospital for 
inpatient treat ment/day surgery. It waives the upfront cash required by the 
hospital, up to the eligible LOG amount. The LOG amount will be computed 
based on the estimated IP payout in respect of the plan’s benefits, subject to the 
respective caps imposed by the insurer( s). The hospital may fully or partially 
waive the deposit in such a case. An insured CPF member may not get the LOG 
if he does not meet the eligibility criteria, for example, if the reason for 
hospitalisation is within his pre -excluded conditions. It is im portant that the 
insured CPF member understands that a LOG may not mean that the insurer 
will pay for the specified amount. To obtain assurance that their bill will be 
covered, the insured CPF member may wish to apply for pre -authorisation 
instead, if avai lable.  
 
5.34 For any insured CPF member who wants to claim from MediShield Life, IP 
and/or MediSave , the hospital will submit the claim on his behalf through the 
MediClaim online system after he has been discharged.  
 
5.35 For MediShield Life claims, the CPF Board will calculate how much MediShield 
Life will pay and  settle the amount directly with the hospital.  
 
5.36 For IP claims, the hospital will submit the claim electronically to the insurers 
directly. For payouts, the IP in surer will calculate how much the IP will pay 
based on the IP benefits, and the CPF Board will independently calculate how 
much MediShield Life will pay based on the MediShield Life benefits. The 
eventual payout will be the higher of the two amounts. For e xample, if the 
payout computed based on the full IP benefits is S$2,000, and the payout based 
on MediShield Life benefits is S$500, the policyholder will receive S$2,000, 
which comprises S$500 from the MediShield Life payout, and S$1,500 from the 
IP’s addi tional coverage payout. In the case where the payout based on 
MediShield Life benefits is higher than the IP benefits, the eventual payout will 
be based on the MediShield Life benefits.  
 
5.37 If the CPF member is making use of his MediSave  to pay for part of hi s bill, the 
hospital will have to submit the claim electronically based on the prevailing 
MediSave  withdrawal limits. Once the claim is approved, the CPF Board will 
make payment to the hospital from the CPF member’s MA. Any outstanding 
amount not covered b y MediShield Life/IP, MediSave  or other private insurance 
(e.g. Group Hospital & Surgical Insurance policy effected by the employer of the 
CPF member) will have to be settled by the patient in cash.  
 
 
 
 
 
 

Health Insurance   
 
194 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] G2.


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Health Insurance   
 
194 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] G2. Claiming From Non -IP Private Insurance  
 
5.38 For someone who is covered by his employer ’s medical benefits or other private 
insurance plans, he will need to show his insurance card (provided by some 
insurers for certain Medical Expense Insurance plans) to the hospital admission 
staff. The hospital may fully or partially waive the deposit in such a case.  
 
5.39 Some hospitals will send the hospitalisation bill directly to the CPF member’s 
non-IP private insurer or employer. In other cases, the insured CPF member will 
have to submit the bill himsel f to the insurer. If the bill is more than the 
reimbursement from the insurer or the employer, he can choose to claim the 
remainder from MediShield Life/his IP and/or his MediSave , up to prevailing 
limits, where applicable.  
 
  

9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         195  
APPENDIX  9A 
Withdrawal Limits for Inpatient, Outpatient, Long -Term Care and Insurance Premiums  
 
MediSave Limits for Inpatient Treatments  
MediSave limits for hospital charges  
Type of hospital stay  MediSave limits for hospital charges  
Inpatient episodes  $550 for the first two days, $400 per day 
afterwards  
Inpatient psychiatric episodes  $150 per day. Maximum of $5,000 a year  
Day surgery episodes  $300 per day  
Surgery episodes  Between $250 and $7,550 depending on the 
complexity of the surgery.  
 MediSave limits for non -acute hospital stays  
Non-acute hospital type  MediSave non -acute hospital limits  
Approved community hospitals  $250 per day. Maximum of $5,000 a year  
Approved convalescent hospitals  $50 per day. Maximum of $3,000 a year  
Approved day hospitals  $150 per day. Maximum of $3,000 a year  
MediSave limits for Assisted Conception Procedure (ACP) Treatments  
ACP Cycle  MediSave Withdrawal Limit  
1st  $6,000  
2nd $5,000  
3rd and subsequent  $4,000 (capped at lifetime MediSave withdrawal 
limit of $15,000 per patient)  
MediSave limits for delivery of a child  
MediSave Maternity Package  Prevailing inpatient limits (up to $550 for the first 
two days and $400 for the third and subsequent 
day in the hospital and applicable surgical 
withdrawal limit depending on the delivery 
procedure) plus an additional $900 for pre -
delivery medical expenses.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Health Insurance   
 
196 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] MediSave Limits for Outpatient Treatments  
MediSave limits for chronic disease management, health screenings and 
vaccinations  
MediSave500 or MediSave700 
Scheme  Patients with complex chronic conditions will be 
able to use up to $700 per patient yearly, while 
other patients will be able to use up to $500 per 
patient yearly (treatment for approved chronic 
conditions are subject to 15% co -payment).  
Additional MediSave limits for elderly  
Flexi -MediSave for Elderly  Patients aged 60 and above can use up to $300 
per patient per year for outpatient medi cal 
treatment, approved vaccinations and 
screenings. Spouse’s MediSave savings can also 
be used if he or she is also over 60 years old.  
MediSave limits for other outpatient treatments  
Outpatient treatment  MediSave outpatient limits  
Renal dialysis treatment  $450 a month  
Outpatient radiotherapy for cancer 
patients  $80 per treatment for external radiotherapy or 
hemi -body radiotherapy  
$360 per treatment for brachytherapy with or 
without external radiotherapy  
$2,800 per treatment for stereotac tic 
radiotherapy  
Radiosurgery treatment for cancer 
patients (Gamma Knife or Novalis 
shaped beam)  Up to $7,500 per treatment  
Chemotherapy for cancer patients 
(includes analgesic medication 
and suppressive treatments)  $1,200 per month per patient  
Scans and other diagnostics for 
cancer patients  $600 per year per patient  
Scans for diagnosis or treatment 
of a medical condition (non -
cancer)  $300 per year per patient  
Anti-retroviral treatment for HIV 
patients  $550 per month per patient  
Hyberbaric oxy gen therapy  $100 per treatment cycle  
Intravenous antibiotic treatment  $600 per weekly cycle.


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Up to $2,400 a year  
Long term oxygen therapy and 
infant continuous positive airway 
pressure therapy  $150 per month per patient  
Immuno -suppressants for patients 
after organ transplants  $300 per month per patient  
Long -term parenteral nutrition  $200 per month  
Autologous bone marrow 
transplant for multiple myeloma 
treatment  $2,800 per year per patient  
Desferrioxamine drug and blood  
transfusion for thalessaemia  $550 per month per patient  
 

9.


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Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         197  
MediSave Limits for Long -Term Care  
MediSave limits for Long -Term Care  
Approved inpatient hospice 
palliative care services  Up to S$250 per day for general palliative care, and 
up to $350 per day for specialised palliative care  
Day Rehabilitation at approved 
day rehabilitation centres  Up to $25 per day for day rehabilitation charges, 
subject to a maximum of $1,500 a year  
Home palliative and day hospice 
care A combined lifetime withdrawal limit of  $2,500 per 
patient for day hospice and home palliative care 
(adults and paediatrics)  
MediSave Care   
MediSave Balance  Monthly Withdrawal 
Quantum  
$20,000  and above  $200  
$15,000 and above  $150  
$10,000 and above  $100  
$5,000 and above  $50 
Below $5,000  Nil 
 
 
MediSave Limits for IP and ElderShield or CareShield Life Supplement Premiums  
Additional Withdrawal Limit (AWL) for IP  
Age next birthday  AWL for IP policyholders 17  
40 and below  $300  
41 to 70  $600  
71 and above  $900  
Additional Withdrawal Limit (AWL) for ElderShield or CareShield Life  Supplements  
ElderShield or CareShield Life  
Supplements  $600 per calendar year per person insured  
  
 
17 https://www.cpf.gov.sg/member/infohub/educational -resources/read -this-before -buying -ip 

Health Insurance   
 
198 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] APPENDIX 9B  
MediShield Life Benefits18 
 
Inpatient/Day Surgery  Claims limits  
Daily Ward and Treatment Charges19  
- Normal Ward  $800 per day  
- Intensive Care Unit Ward  $2,200 per day  
*An additional claim limit of $200 per day applies for the first two inpatient days  
- Psychiatric (Up to 60 days per policy year)  $160 per day  
- Community Hospital(Rehabilitative)  $350 per day  
- Community Hospital (Sub -acute)  $430 per day  
- Inpatient Palliative Care Service (General)  $250 per day  
- Inpatient Palliative Care Service (Speciali sed) $350 per day  
Surgical Procedures  A B C 
- Table 1 A/B/C (less complex procedures)  $240  $340  $340  
- Table 2 A/B/C  $580  $760  $760  
- Table 3 A/B/C  $1,060  $1,160  $1,280  
- Table 4 A/B/C  $1,540  $1,580  $1,640  
- Table 5 A/B/C  $1,800  $2,180  $2,180  
- Table 6 A/B/C  $2,360  $2,360  $2,360  
- Table 7 A/B/C (more complex procedures)  $2,600  $2,600  $2,600  
Implants  $7,000 per treatment  
Radiosurgery  $10,000 per course of treatment  
Autologous Bone Marrow Transplant Treatment 
for Multiple Myeloma  $6,000 per treatment  
Outpatient Treatment  
Chemotherapy for Cancer  $3,000 per month  
Radiotherapy for Cancer   
- External (Except Hemi -Body)  $300 per treatment  
- Brachytherapy  $500 per treatment  
- Hemi -Body  $900 per treatment  
- Stereotactic  $1,800 per treatment  
Kidney Dialysis  $1,100 per month  
Immunosuppressants for Organ Transplant  $550 per month  
Erythropoietin for Chronic Kidney Failure  $200 per month  
Long -term Parenteral Nutrition  $1,700 per month  
Maximum Claim Limits  
Per Policy Year  $150,000  
Lifetime  No Limit  
  
 
18 https://www.moh.gov.sg/home/our -healthcare -system/medishield -life/what -is-medishield -life/what -
medishield -life-benefits  
19 Includes meal charges, prescription, profess ional charges, investigations and other miscellaneous 
charges  

9. Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         199  
Deductible20  
(Based on age next birthday at the start of the policy year. Applicable for admissions 
or treatments received on or after 1/3/2021.)


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Applicable for admissions 
or treatments received on or after 1/3/2021.)  
Ward Class / Treatment  Age 80 and below  81 and above  
 
Class C1 $1,500  $2,000  
Class B2 and above 
(including stay in private 
hospital)  $2,000  $3,000  
Day Surgery  $1,500  $2,000  
Outpatient Treatments  Not Applicable  
1Subsidised patients will follow the deductible for Class C and non -subsidised 
patients will follow the deductible for class B2 for Community Hospital, Inpatient 
Palliative Care Service, Short Stay Wards and Continuation of Autologous Bone 
Marrow Transplant  for Multiple Myeloma.  
Co-insurance  
Inpatient/Day Surgery  
Claimable amount accumulated within a policy year  
First S$5,0002 10% 
Next $5,000  5% 
Above $10,000  3% 
Outpatient Treatment  10% 
2Inclusive of deductible  
 
  
 
20 https://www.moh.gov.sg/home/our -healthcare -system/medishield -life/what -is-medishield -life/how -to-
make -a-medishield -life-claim  

Health Insurance   
 
200 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] APPENDIX 9 C 
 
LIA Standardise Pre -Authorisation Form (To Be Completed By Attending Doctor)  
 
 
 
 PRE-AUTHORISATION FORM TO BE COMPLETED BY ATTENDING DOCTOR  
(Indicate “NA” if not applicable.)  
 
    Fill dates in format “DDMMYYYY”  
Name  of Patient   NRIC / FIN  No 
A. Details of Hospitalisation  
  Name  of Principal  Doctor  and Clinic  
 
  Name  of Hospital / Surgery  Centre  
Preferred Ward  Type  
Private  
  Day Surgery    2 Bed 
  Standard  Single  Bed   4 Bed    
 Others:  
 
Public/Restructured  
  Day Surgery  (subsidised)     Class  B1/B1+    
 Day Surgery  (non-subsidised)                 Class  B2/B2+  
 Class  A    Class  C  Date  of Admission  Est. Length  of Stay (No. 
of days)  
 
 
Is the condition typically managed on an 
outpatient basis? If Yes, please provide 
reason for this hospitalisation.  
  No       Yes, reasons  are: 
Date  of first consultation  
of symptoms  
 
 
 Date  of diagnosis/  
provisional  diagnosis  Diagnosis / Provisional diagnosis in ICD 10 
AM with description  
Date  of onset  of symptoms  / Duration  of symptoms  Description  of symptoms  
Did the patient come to see you with a referral letter?  
  No        Yes  
(If a referral letter is available, please attach a copy to speed 
up the pre -authorisation process.)  Based on the information available to you, 
does the patient have any of the following 
major co -morbidities? (Note: Only co -
morbidities that have impact on the patient’s 
treatment, impact on the dura tion of 
hospitalisation, or which are medically related to 
the patient’s condition, need to be indicated.)  
 
Based on the information available to you, is the event 
for which pre -authorisation is being requested:  
 
   For a routine check -up/screening  
   Related to a clinical trial/study  
   Related to self -inflicted injuries/attempted  suicide  
   Related to alcohol/drug abuse  
   Related to a congenital  anomaly/genetic  disorder  Comorbidities  Date of 
diagnosis, 
if  available  
 Cancer   
 Stroke, Heart Failure,  
    Cardiovascular Disease   
 Diabetes   Insert Company Logo, if applicable  

9.


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Part I Healthcare Financing  
 
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                         201  
   Related to a mental/psychiatric di sorder  
   Related to an elective cosmetic procedure  
   Related to a dental procedure  
   Related to an STD or HIV/AIDS   Hyperlipidaemia   
 Hypertension   
Name of Clinic and Doctor who had treated the patient 
for the above comorbidity, if available  
 
 
 
 
 
  Kidney Failure   
 Other Significant Comorbidities 
that impact the patient’s care 
(Please state):  
 
  
B.   Best Estimated Costs   
 S$ 
1. Total Professional Fees  
Breakdown as:  
 
TOSP Code and Description:  
 
Surgeon fees  S$ 
Anaesthetist fees  S$ 
 
TOSP Code and Description:  
 
Surgeon fees  S$ 
Anaesthetist fees  S$ 
 
TOSP Code and Description:  
 
Surgeon fees  S$ 
Anaesthetist fees  S$ 
  
……………
…………  
2. Total Attendance Fees  
 
  
……………
…………  
 
3. Total of Other Fees (E.g.  Secondary treating doctors’ fees, surgical implants, medical 
consumables, and other charges.)  
Breakdown as:  
a.  S$ 
b.  S$ 
c.  S$ 
d.  S$ 
 …………
…………
… 
 
4. Total Hospital Charges  
 
  
…………
…………
… 
5. Total Bill Size = 1 + 2 + 3 + 4  
 
  
…………
…………...  
 
 
 
 
 

Health Insurance   
 
202 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] C.   Principal Doctor’s Declaration & Signature  
 
 
1. I represent and warrant that:  
(a) I have personally examined and treated the Insured (i.e.  patient) in respect of the medical condition 
described above and that the information stated above represent my genuine and honest opinion of 
his/her condition and my recommended treatment; and  
(b) the answers given above are true, accurate and complete to th e best of my knowledge and belief and 
that no information has been withheld.  
 
2. I agree and authorize (name of insurer) to release this medical information, with the patient’s consent if 
such disclosure is required by the Financial Industry Disputes Resoluti on Centre Ltd (FIDReC) of 
Singapore or any claim dispute resolution organisation.  
 
                                                                                                              Official Stamp of Hospital / Clinic  
Name of Doctor:   ________________________________  
 
 
Doctor’s MCR: __________________________________  
 
 
 
Doctor’s Signature and Date: ___________________________  
 
 
© Copyright 2022 Life Insurance Association Singapore  
Version 20220117  for implementation from April 2022   
Source:  https://www.lia.org.sg/media/3278/lia -pre-authorisation -form_ -20220117.pdf  
 
 
 

28
HEALTHCARE FINANCING PART I & IICHAPTER
09
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Singapore government 
subsidies • Government provides funding to public healthcare institutions (e.g. public 
hospitals, national specialty centres and polyclinics), as well as selected private 
clinics and voluntary welfare organisations (VWOs).
• Means-test is used to target subsidies, so that needy patients can receive 
more help; lower-income patients receive more subsidies than higher-income 
patients.
Main components of 
Singapore’s Healthcare 
Financing System
MediSave • National healthcare savings scheme in Singapore under the Central Provident 
Board (CPF) umbrella.
• Contributions to the Medisave Account (MA) are subject to a maximum amount, 
known as the Basic Healthcare Sum (BHS). The BHS is designed to be enough 
for a CPF member’s basic, subsidised healthcare needs in his old age. Hence, 
amounts in the MA up to the BHS cannot be withdrawn as cash.
• Amounts above the BHS will flow to the CPF member’s Special or Retirement 
Accounts to boost his monthly payouts. If the CPF member has already met his 
Full Retirement Sum, the amounts will flow to his Ordinary Account, and can be 
withdrawn as cash from the age of 55 years.
• Can be used to pay for the CPF member’s medical expenses at all accredited 
institutions, in both the public and private sector.
• Can also be used to pay for medical expenses of the CPF member’s approved 
dependents, namely his spouse, children, parents, siblings, and grandparents. If 
paying for a sibling or grandparent, the patient must be a Singapore Citizen or 
Singapore Permanent Resident (SPR).


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If 
paying for a sibling or grandparent, the patient must be a Singapore Citizen or 
Singapore Permanent Resident (SPR).


29
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Uses of MediSave Account
How much Medisave can 
be usedThe use of MediSave is subject to:
• Withdrawal Limit.
• Additional Withdrawal Limit (AWL).
Payments via MediSave are allowed in all public healthcare institutions, as well as 
approved private hospitals and medical institutions
Distribution Of MediSave 
Upon Demise• If a patient was hospitalised just before death and had authorised the use of his 
MediSave to pay for his medical bill, his MediSave balance would be used in full, 
without being subject to the existing MediSave withdrawal limits, to pay for his 
last inpatient medical bill.
• If the patient had not authorised the use of his MediSave before his demise, his 
immediate family member (spouse, parent, or child who is aged 21 years and 
above), or donee or deputy can also do so for the last inpatient medical bill, 
provided that it has not been paid out to the patient’s nominated beneficiaries.
• In the event that the patient does not have any immediate family member, 
or donee or deputy to authorise the use of the patient’s MediSave, a relative 
who has been taking care of the patient may also write to MOH through the 
hospital to seek approval for the relative to authorise the withdrawal of patient’s 
MediSave, to pay for the last inpatient medical bill.
• Remaining MediSave balance, after the payment of the last medical bill, would 
be distributed to the nominated beneficiaries of the patient’s CPF account if a 
nomination was made before his death. If there was no nomination made, the 
balance in the deceased patient’s MA would be distributed by the Public Trustee 
to his family members under the intestacy laws for non-Muslims, or the Muslim 
inheritance law for Muslims.Uses of Medisave Items that can be paid using MediSave
Outpatient 
TreatmentsSelected outpatient treatments such as:
• Approved chronic conditions under the chronic 
disease management programme
• Vaccinations
• Health screenings
Inpatient Treatments Inpatient care  which includes:
• Inpatient episodes 
• Inpatient psychiatric episodes
• Day surgery
• Assisted Conception Procedures
Long-Term Care Long-Term Care treatments which include: 
• Rehabilitative care
• Palliative care
• Disability care
Insurance Premiums Premium payments of: 
• MediShield Life
• ElderShield/CareShield Life
which can be fully paid with MediSave
• Integrated Shield Plans and ElderShield/CareShield 
Life supplements
which are subject to withdrawal limits periodically 
reviewed by MOH

30
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
MediShield Life • Basic healthcare insurance scheme.
• Covers all Singapore Citizens and Singapore Permanent Residents against large 
medical bills for life, regardless of age or health conditions.
• The claim limits are sized to cover subsidised bills incurred for hospitalisation in 
class B2/C wards, day surgery, and selected costly outpatient treatments (e.g., 
dialysis and chemotherapy) in the public hospitals.  
• However, MediShield Life benefits are designed based on Class B2/C bills, so 
as to keep premiums affordable. Those who would like additional coverage in 
Class A/B1 wards or private hospitals may consider buying Integrated Shield 
Plans (IP).
• No need to apply for MediShield Life. All SCs and PRs are automatically covered 
under MediShield Life from 1 Nov 2015. New SCs are covered from birth or 
from the day they attain citizenship. PRs are covered from the day they attain 
permanent residency.
• MediShield Life premiums may be fully paid from MediSave.
• Please refer to the Study Text for a list of treatment items, procedures, 
conditions, activities which are not covered by MediShield Life and cannot be 
claimed.
MediShield Life Premiums • Actuarially priced based on the health risks and expected healthcare utilisation 
of each age group so that each age group’s payouts are broadly supported by 
their own premiums.
• Those with pre-existing medical conditions can enjoy coverage for their 
conditions. Only those with serious pre-existing medical conditions listed in the 
MOH website need to pay a nominal Additional Premium of 30% for the first 10 
years, in addition to the standard MediShield Life premiums.
• One can pay premiums from own MediSave, or family members may pay one’s 
premium using their MediSave. Parents may also tap on the MediSave Grant for 
newborns to pay for their child’s MediShield Life premiums.


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• One can pay premiums from own MediSave, or family members may pay one’s 
premium using their MediSave. Parents may also tap on the MediSave Grant for 
newborns to pay for their child’s MediShield Life premiums.
How Are MediShield Life 
Claim Payouts Computed?• Pays on a reimbursement basis, subject to the claim limits imposed on the 
covered medical expenses, as well as deductible, co-insurance and pro-ration 
factors.
• The deductible is the fixed amount payable by the insured each policy year (the 
year following his policy renewal month), before the MediShield Life payout 
starts. The deductible is payable only once every policy year.
• Co-insurance is the patient’s share of the claimable amount which the insured 
will have to pay, along with the deductible.
Please refer to the Study Text for example of how the reimbursement under 
MediShield Life is arrived at.
Integrated Shield Plans Integrated Shield Plans (IPs) are MediSave-approved hospitalisation insurance plans 
made up of two parts. 
• MediShield Life component administered by the CPF Board. 
• An additional private insurance coverage component administered by approved 
private insurers, typically to cover Class A/B1 wards of public hospitals or 
private hospitals. 
No duplication of coverage between IPs and MediShield Life.

31
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Consideration on 
Integrated Shield Plans (IP)• With the different IPs available, it is necessary for the sellers of such plans to 
understand the different plans offered in the insurance market, and to advise 
their prospective clients, based on the needs and long-term affordability of each 
individual client’s position.
• As part of due diligence, clients should be informed of the key differences 
in premiums, benefits, exclusions, deductibles, co-insurance and other co-
payment features between the various IPs offered by their insurer, versus 
MediShield Life. There are different benefits provided in the IP policy, and plans 
can be “as charged” or “non -as-charged” (i.e. they have sub-limits imposed). 
Information provided should be easy to understand, unambiguous and clearly 
explained to help clients make an informed decision.
• Clients should consider if they would wish to stay in a private or subsidised 
ward in a public hospital, or in a private hospital, and if they wish to choose 
their own doctors.
• Clients should consider if they can afford their IP premiums in the long term as 
the policyholders may have to pay a substantial portion of their IP premiums in 
cash, especially at the older ages.
• Unlike MediShield Life which provides coverage for pre-existing medical 
conditions (with Additional Premiums for the first 10 years), the coverage for 
the private insurance component of the IP may be declined or imposed with 
exclusions for pre-existing conditions. The private insurance component may 
also have premium loading, arising from pre-existing conditions.
How MediSave can be used 
to meet a CPF member’s 
healthcare needs and buy 
approved Medical Expense 
Insurance?MediSave can be used to pay premiums for IPs, either in full or in part, depending 
on the age group and the IP plan type. From 1 November 2015, MediSave use for 
the additional private insurance component of the IP premiums is subject to the 
new Additional Withdrawal Limit (AWL). The AWL is set per insured person per 
policy year, as stated below:
• Age Next Birthday (ANB) 40 years and below: S$300 
• ANB 41 to 70 years: S$600
• ANB 71 years and above: S$900
How MediShield Life 
premiums are kept 
affordable?• Premium Subsidies for lower- to middle-income.
• Pioneer and Merdeka Generation Subsidies.
• COVID-19 Subsidies.
• Additional premium support.
How MediShield Life 
interacts with Integrated 
Shield Plans?MediShield Life Scheme Integrated Shield Plan (IP) 
It is administered by the CPF Board It is administered by private insurers, 
as approved by MOH.
Its coverage is sized for stays in Class 
B2/C wards of public hospitals.It provides for enhanced coverage 
beyond MediShield Life, with various 
plan types available for stays in private 
hospitals and/or Class A/B1 wards of 
public hospitals.
It covers all pre-existing conditions. Coverage for the private insurance 
component of the IP may be declined 
or imposed with exclusions and/or 
premium loading, arising from pre-
existing conditions.
There is no minimum or maximum age 
limit.It may have a minimum or maximum 
entry age limit.
There are sub-limits applicable. It may have sub-limits, although most 
do not have sub-limits.


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There is no minimum or maximum age 
limit.It may have a minimum or maximum 
entry age limit.
There are sub-limits applicable. It may have sub-limits, although most 
do not have sub-limits.
MediShield Life premiums are fully 
payable by MediSave.MediShield Life component of the IP 
is fully payable by MediSave, while 
private insurance component of 
the IP is payable by MediSave up to 
Additional Withdrawal Limit, and the 
remainder is payable by cash.
All Singapore Citizens and Permanent 
Residents are automatically covered 
for life. No application is required.Application to private insurers is 
required.
31

32
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Standard IP • “No frills” product targeted at covering large Class B1 ward hospital bills and 
selected outpatient treatments.
• Affordable option for Singapore Citizens and Permanent Residents who want 
additional coverage beyond MediShield Life and may find other higher coverage 
IPs too expensive.
Riders • Pay for the co-insurance and deductible portion of the IP, and may pay cash 
payouts upon hospitalisation.
Need for Co-Payments • Co-payment is an important principle in the design of healthcare insurance. It 
encourages policyholders and their doctors, to consider the necessity of the 
medical treatment and its cost, so that they can make an informed decision 
on the appropriate healthcare services. This encourages prudence and keeps 
healthcare cost, and health insurance premiums, affordable and sustainable in 
the long term.
Terminating or Switching 
IP/Switching Insurer• An IP policyholder who cannot afford, or does not wish to continue paying the 
premium for his IP, can  switch his plan to a lower coverage plan within the 
same insurer at any point in time, without additional underwriting involved. 
• He can also  terminate his IP at any point in time, and still be covered by 
MediShield Life which provides basic health insurance, regardless of any pre-
existing conditions.  
• If the person with an existing IP switches to a new IP with another insurer, 
Original IP with the previous insurer will be automatically terminated.
• Option to go back to the previous insurer within 30 days from the date of 
notification of termination from the previous insurer.
Risk-Loading by private 
insurers• MOH allows IP insurers to risk-load insured members with pre-existing 
conditions for the private insurance component of the IPs.
Benefits in having Pre-
Authorisation for IP• Insurers can assess the medical necessity and cost of treatment to ensure it is 
within the terms and conditions of the policy’s coverage.
• Patients will have a peace of mind in knowing that their procedure is within 
their insurance coverage; and
• Healthcare providers have better clarity on the type of procedures covered by 
insurance to better advise their patients prior to the actual procedure. 
Policyholders are thus encouraged to seek pre-authorisation for planned 
procedures as far as possible if the option is provided by the insurer.
Claims process of 
MediShield Life, Integrated 
Shield Plans, other Medical 
Expense Insurance and 
MediSaveAny insured CPF member who wishes to claim from his MediShield Life, IP and/or 
MediSave will need to complete the Medical Claims Authorisation Form to:
• Allow the hospital to claim from his insurer; and 
• Instruct the CPF Board to deduct from his MA to pay for his hospital bill, while 
the insurer settles the claim.
For any insured CPF member who wants to claim from MediShield Life, IP and/or 
MediSave, the hospital will submit the claim on his behalf through the MediClaim 
online system after he has been discharged.
If there is no pre-authorisation, the insured CPF member under an IP can approach 
the hospital to trigger a request for a Letter of Guarantee (LOG) from his insurer 
upon hospital admission. It is important that the insured CPF member understands 
that a LOG may not mean that the insurer will pay for the specified amount. To 
obtain assurance that their bill will be covered, the insured CPF member may wish 
to apply for pre-authorisation instead, if available.
For someone who is covered by his employer medical benefits or other private 
insurance plans, he will need to show his insurance card (provided by some insurers 
for certain Medical Expense Insurance plans) to the hospital admission staff. The 
hospital may fully or partially waive the deposit in such a case.
• Some hospitals will send the hospitalisation bill directly to the CPF member’s 
non-IP private insurer or employer. In other cases, the insured CPF member will 
have to submit the bill himself to the insurer. 

33
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Withdrawal Limits for 
Inpatient, Outpatient, 
Long-Term Care and 
Insurance PremiumsPlease refer to the Study Text for the full list.


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33
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Withdrawal Limits for 
Inpatient, Outpatient, 
Long-Term Care and 
Insurance PremiumsPlease refer to the Study Text for the full list.
MediShield Life Benefits Please refer to the Study Text for the full list.
ElderShield & ElderShield 
SupplementsElderShield is a long-term care insurance scheme launched in September 2002. It 
provides basic financial protection to those who need long-term care, especially 
during old age.
ElderShield Supplement plans complement the current ElderShield scheme, by 
offering additional benefits at different pricing levels which increase the insured’s 
coverage through:
• Increasing the monthly payout;
• Extending the payout period; or
• A combination of both.
How ElderShield and 
ElderShield Supplements 
work?• To purchase and maintain an ElderShield Supplement, an insured must have an 
ElderShield policy.
• Premiums for ElderShield Supplement can be paid using MediSave (up to a limit 
of S$600 per insured per calendar year) and/or by cash.
• The ElderShield scheme will pay a monthly benefit of either S$300 up to 60 
months, or S$400 up to 72 months, depending on the type of the scheme in 
which the CPF member is covered.
Eligibility Criteria For 
Payment Of ElderShield 
benefits• Meets the waiting period requirement.
• Unable to perform the specified number of activities of daily living 
• Meets the deferment period requirement (If he recovers from the disability 
within the period, then no benefits are payable).
• Please also note on making a claim under ElderShield and how the benefits are 
paid.
Features of ElderShield • Non-forfeiture feature.
• Guaranteed renewability on an annual basis.
• Worldwide coverage.
• Minimum (i.e. 40 years old) and maximum entry age (i.e. 64 years old).
• Grace period of 75 days is allowed for payment of the overdue premiums.
• Reinstatement of the policy is allowed within 180 days from the expiry of the 
grace period, subject to evidence of insurability at the insured’s expense and 
payment of the overdue premiums with interest.
• Insurer has the right to appoint an assessor to examine the insured periodically.
• Where the insured is overseas at the time of a claim, the insurer has the right 
to commute the benefit payments to a single payment reflecting the present 
value of future benefit payments, or withhold the claim payment if it is unable 
to assess the claim after having made reasonable attempts to do so.
• No cash surrender value.
• Free-look period of 60 days from the policy commencement date during which 
the insured may cancel his policy, and receive a full refund of the premiums 
paid.

34
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Exclusions of ElderShield • Self-inflicted injury, suicide or attempted suicide;
• Alcoholism or drug addiction; or
• War, whether declared or undeclared.
• CPF members who are suffering from pre-existing disabilities, will not be 
covered under ElderShield.
Termination of cover for 
ElderShield• Expiry of the grace period if the ElderShield policy is not eligible for the non-
forfeiture benefit (i.e. it has been in force for too short a period for it to acquire 
sufficient reserves to be converted into a paid-up policy);
• Death of the insured;
• Date in which the last benefit payment has been received; or
• Date in which the written notice from the insured to cancel the policy is received 
by the insurer (if the policy does not have sufficient reserves, it will not be 
converted into a paid-up policy).
ElderShield to CareShield 
Life• ElderShield became a  closed scheme from 1 August 2021.
• The Government had taken over the ElderShield administration from 1 
November 2021.
• New cohorts born in 1980 or later were covered under CareShield Life from 1 
Oct 2020 but Singapore Citizens and SPRs born in 1979 or earlier could still opt 
in to the ElderShield scheme up till 1 Aug 2021 if they are below 65. 
• Existing ElderShield policyholders could continue to remain covered under the 
scheme with no changes to their coverage and benefits.
CareShield Life & 
CareShield Life 
SupplementsCareShield Life was introduced in 2020, as an enhancement of ElderShield and is 
administered by the Government on a not-for-profit basis, and offers;
• Better protection and higher payouts that increase over time, so that claimants 
can better afford their basic long-term care needs; and 
• Protection for life.
Any CareShield Life policyholder who wishes to obtain higher long-term care 
insurance coverage can also purchase Supplements.


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Any CareShield Life policyholder who wishes to obtain higher long-term care 
insurance coverage can also purchase Supplements. Supplements are plans which 
complement one’s basic CareShield Life plan by offering additional benefits, such as 
higher monthly payout amounts, which enhances the coverage. 
CareShield Life premium 
subsidies and supportTo ensure that no one will lose CareShield Life coverage due to genuine inability to 
pay, the Government provides the following premium subsidies and support:
• Means-tested premium subsidies of up to 30% of premiums of CareShield Life, 
to help lower- to middle-income households.
• Participation incentives of up to $2,500 for Singapore Citizens, if they join 
CareShield Life by 31 December 2023, to encourage those born in 1979 or 
earlier to join CareShield Life.
• Additional participation incentives of $1,500 for Merdeka and Pioneer 
Generation citizens if they join CareShield Life by 31 December 2023.
• Additional Premium Support for Singaporeans who are unable to pay their 
CareShield Life premiums even after premium subsidies, so that no one will lose 
coverage under CareShield Life due to genuine inability to pay premiums.
Enhanced benefits under 
CareShield LifeCareShield Life features higher payouts that increase over time with no cap on 
payout duration, to provide better protection against the uncertainty of long-term 
care costs in the event of severe disability. 
• Lifetime cash payouts for as long as the policyholder is severely disabled.
• Payouts increase until age 67 or when a claim is made, whichever is earlier, with 
payouts starting at S$600 per month in 2020.
CareShield Life Premiums • The CareShield Life scheme makes use of pre-funded premiums i.e. the insured 
CPF members pay more than the cost of their health risk, while they are 
younger, to cover for the higher risk in their later years.
• For Singapore Residents born 1980 or later (future cohorts),  premiums are paid 
from the age of enrolment until age 67. Premiums will increase over time, to 
support payout increases.
• Singapore Residents born in 1979 or earlier (existing cohorts) will pay a base 
premium.
• Fully payable by MediSave.

35
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Eligibility Criteria for 
Payment of CareShield Life 
BenefitsSimilar to that of ElderShield.
Other key features of 
CareShield Life• Guaranteed renewable on an annual basis.
• Worldwide coverage.
• Minimum entry age of 30 years old, but no maximum entry age.
• CareShield Life policy will be terminated if the insured is no longer a Singapore 
Citizen or SPR.
• No cash surrender value.
Other healthcare financing 
schemes set up by the 
Singapore government• Pioneer Generation Package;
• Merdeka Generation Package;
• Interim Disability Assistance Programme For The Elderly (IDAPE);
• ElderFund and
• Medifund.
• COVID-19 Medical Bills
Interim Disability 
Assistance Programme For 
The Elderly (IDAPE)• IDAPE was launched by the Government to take care of Singaporeans who were 
not eligible to join the ElderShield scheme, when it was launched in September 
2002, either because they exceeded the maximum entry age or they had a pre-
existing disability.
Singaporean will qualify for IDAPE if:
• He is unable to perform three or more of the 6 Activities of Daily Living (ADL) - 
washing, feeding, dressing, toileting, mobility and transferring.
• He is a Singapore citizen born before 30 September 1932 OR born between 
1 October 1932 and 30 September 1962 (both dates inclusive) but with pre-
existing disabilities as at 30 September 2002.
• His per capita household monthly income is $2,800 or less OR he has no 
household income and is living in a residence with Annual Value of $13,000 and 
below.
IDAPE Payout
*An IDAPE applicant from a household with no income will qualify for the S$250 
monthly payout if the annual value of his place of residence is S$13,000 or lower.
ElderFund ElderFund is a discretionary assistance scheme launched on 31 January 2020. It is 
targeted at severely disabled lower-income Singapore Citizens aged 30 and older, 
who are not able to benefit from CareShield Life, ElderShield, and the Interim 
Disability Assistance Programme for the Elderly (IDAPE), have low MediSave 
balances and have inadequate personal savings to meet their long-term care needs.
MediFund MediFund is an endowment fund set up by the Government.


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MediFund MediFund is an endowment fund set up by the Government. It provides a safety net 
for needy Singaporeans who face difficulties paying for their remaining healthcare 
bills after Government subsidies, insurance and MediSave.Per Capita Household Income*IDAPE Payout
(With Effect From 1 July 2013)
(a) S$0 to S$2,000 (a) S$250 per month for up to 72 
months
(b) S$2,001 to S$2,800 (b) S$150 per month for up to 72 
months

9. Part II Healthcare Financing  
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                    203  
0      CHAPTER 9  
PART II  
HEALTHCARE FINANCING  
 
 
 
CHAPTER OUTLINE  
 
6. ElderShield & ElderShield Supplements  
7. CareShield Life & CareShield Life Supplements  
8. Other Healthcare Financing Schemes Set Up By The Singapore Government  
 
 
LEARNING OUTCOMES  
 
After studying this chapter, you should be able to:  
▪ describe how ElderShield and ElderShield Supplements work  
▪ explain the shift from ElderShield to CareShield Life  
▪ describe the enhanced benefits under CareShield Life  
▪ describe other healthcare financing schemes set up by the Singapore 
Government:  
- Pioneer Generation Package  
- Merdeka Generation Package  
- Interim Disability Assistance Programme for the Elderly  (IDAPE)   
- ElderFund  
- MediFund  
- COVID -19 Medical Bills  paid by the Singapore Government  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Health Insurance   
 
204 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] Contents  
CHAPTER OUTLINE  ................................ ................................ ................................ ................................ ...........  203 
LEARNING OUTCOMES  ................................ ................................ ................................ ................................ .... 203 
6. ELDERSHIELD  & ELDERSHIELD SUPPLEMENTS  ................................ ................................ ...................  205 
A. Eligibility Criteria For Payment Of ElderShield Benefits  ................................ ...............................  206 
A1.  Meets The Waiting Period Requirement  ................................ ................................ ...............  206 
A2. Unable To Perform The Specified Number Of Activities Of Daily Living As Defined  ........  206 
A3. Meets The Deferment Period Requirement ................................ ................................ ...........  207 
B. How To Make A Claim Under ElderShield?  ................................ ................................ ...................  207 
C. How Are ElderShield Benefits Paid? ................................ ................................ ...............................  207 
D. Non-Forfeiture Feature  ................................ ................................ ................................ ....................  208 
E. Other Key Features Of ElderShield  ................................ ................................ ................................ . 208 
F. Exclusions  ................................ ................................ ................................ ................................ ........  208 
G. Termination Of Cover  ................................ ................................ ................................ ......................  209 
H. Government Administration of ElderShield  ................................ ................................ ..................  209 
7. CARESHIELD LIFE AND CARESHIELD LIFE SUPPLEMENTS  ................................ ................................ . 210 
A. Coverage  ................................ ................................ ................................ ................................ ..........  211 
B. Benefits Under CareShield Life  ................................ ................................ ................................ ....... 211 
C. CareShield Life Premiums  ................................ ................................ ................................ ...............  212 
D. Pioneer and Merdeka Generation Incentives  ................................ ................................ .................  213 
E. Eligibility Criteria for Payment of CareShield Life Benefits  ................................ ..........................  214 
E1. Unable To Perform The Specified Number Of Activities Of Daily Living As Defined  ........  214 
E2. Meets The Deferment Period Requirement ................................ ................................ ...........  214 
F. How to Make a Claim Under CareShield Life?  ................................ ................................ ...............  214 
G. Other Key Features of CareShield Life  ................................ ................................ ...........................  214 
8. OTHER HEALTHCARE FINANCING SCHEMES SET UP BY THE SINGAPORE GOVERNMENT  ...........  215 
A. Pioneer Generation Package  ................................ ................................ ................................ ...........  215 
A1. Outpatient Care  ................................ ................................ ................................ .......................  215 
A2. MediShield Life  ................................ ................................ ................................ .......................  215 
A3. MediSave Top -ups ................................ ................................ ................................ ..................  215 
A4. Pioneer Generation Disability Assistance Scheme  ................................ ...............................  216 
A5. CareShield Life  ................................ ................................ ................................ ........................  216 
B. Merdeka Generation Package  ................................ ................................ ................................ .........  216 
B1. Passion Silver Card Top -Ups................................ ................................ ................................ .. 216 
B2. MediSave Top -Ups ................................ ................................ ................................ .................  217 
B3.


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Passion Silver Card Top -Ups................................ ................................ ................................ .. 216 
B2. MediSave Top -Ups ................................ ................................ ................................ .................  217 
B3. Outpatient Care  ................................ ................................ ................................ .......................  217 
B4. MediShield Life  ................................ ................................ ................................ .......................  217 
B5. CareShield Life  ................................ ................................ ................................ ........................  217 
C. Interim Disability Assistance Programme For The Elderly (IDAPE)  ................................ .............  217 
D. ElderFund  ................................ ................................ ................................ ................................ .........  218 
E.  MediFund  ................................ ................................ ................................ ................................ .........  219 
F.  COVID -19 Medical Bills  ................................ ................................ ................................ ....................  219 
 


9. Part II Healthcare Financing  
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                    205  
 
6. ELDERSHIELD & ELDERSHIELD SUPPLEMENTS  
 
6.1 ElderShield  is a long -term care  insurance scheme launched in September 2002.  
It provides basic financial protection to those who need long -term care, 
especially during old age.  
 
6.2 Unlike MediShield Life, which is compulsory for all, ElderShield  is an opt -out 
scheme. That means that all Singaporeans and Permanent Residents (PRs) can 
choose to opt -out of the insurance scheme if they wish to. For new cohorts born 
in 1980 and after, they would be enrolled into CareShield Life instead of 
ElderShield on 1 Oct 2020 or when they turned 30, whichever is later. Those 
born in 1979 or earlier have the option to enroll in CareShield Life.  
 
6.3 Premiums  can be paid fully through MediSave . There are currently two 
ElderShield schemes, namely ElderShield300 and Elder Shield400.  
ElderShield300 was launched on 30 September 2002 offering a cash payout of 
S$300 per month for a maximum of 60 months. ElderShield400 was introduced 
in 2007 offering an improved coverage with cash payout of S$400 per month 
for a maximum of 72 months.  Singapore Citizens and SPRs who join 
ElderShield after 30 September 2007 will be on the ElderShield400 scheme.  
 
6.4 Before 1 November 2021, the Government had appointed three private insurers, 
Aviva Ltd (now known as Singlife with Aviva), Great Eastern  Life Assurance Co 
Ltd and  Income Insurance Limited , to offer ElderShield. Any CPF member who 
is a Singapore Citizen or SPR and who attains the age of 40 years is 
automatically covered under the scheme if he/she d oes not opt out. No 
registration or medical assessment is needed. SCs or SPRs between the ages 
of 40 and 64 can also choose to opt in to the ElderShield scheme, but with 
medical underwriting.  
 
6.5 The Government had taken over the ElderShield  administration from 1 
November 2021 and ElderShield had become a closed scheme from 1 August 
2021 onwards. New cohorts born in 1980 or later were covered under 
CareShield Life from 1 Oct 2020 (more details in Section 7 of this Chapter), but 
Singapore Citi zens and SPRs born in 1979 or earlier could still opt in to the 
ElderShield scheme up till 1 Aug 2021 if they are below 65. Existing ElderShield 
policyholders could continue to remain covered under the scheme with no 
changes to their coverage and benefits.  
 
6.6 It should be noted  that any existing ElderShield insured who wishes to obtain 
higher severe disability insurance coverage can purchase ElderShield 
Supplement s. ElderShield Supplement plans complement the current 
ElderShield scheme , by offering additional  benefits at different pricing levels 
which increase the insured’s coverage through:  
(a) increasing the monthly payout;  
(b) extending the payout period; or  
(c) a combination of both.  
 
 


Health Insurance   
 
206 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] 6.7 To purchase and maintain an ElderShield  Supplement, an insured must have 
an ElderShield policy. Premiums for ElderShield Supplement can be paid using 
MediSave (up to a limit of S$600 per insured per calendar year) and/or by cash. 
As ElderShield and ElderShield Supplements are structured as stan d-alone 
policies, claims can be made under both policies if the insured fulfils the claim 
eligibility criteria. The Supplement plans are only offered by the three approved 
insurers who were administering ElderShield prior to 1 November 2021.


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The Supplement plans are only offered by the three approved 
insurers who were administering ElderShield prior to 1 November 2021.  
 
A. Eligibility Criteria For Payment Of ElderShield Benefits  
 
A1.  Meets The Waiting Period Requirement  
 
6.8 There is a waiting period of 90 days from the policy commencement date. The 
benefit will not be payable if the insured becomes disabled in the first 90 days 
of coverage. Instead, the insurer will terminate the policy and refund all the 
premiums paid. However, the waiting period does not apply if the disablement 
is due solely to an accident.  The waiting period is waived for policyholders who 
were auto enrolled . 
 
A2. Unable To Perform The Specified Number Of Activities Of Daily Living As 
Defined   
 
6.9 The ElderShield scheme will pay a monthly benefit of either S$300 up to 60 
months, or S$400 up to 72 months, depending on the type of the scheme in 
which the CPF member is  covered. It pays the benefits  if the insured is unable  
to perform  at least three of the  six Activities of Daily Living (ADLs)  as illustrated 
in the diagram below : 
 
 
 
 
 
 
 
 
 
6.10 The ADLs are defined as below:  
(a) Washing  – the ability to wash in the bath or shower (including getting into 
and out of the bath or shower) or wash by other means.  
(b)  Dressing  – the ability to put on, take off, secure and unfasten all garments 
and, as appropriate, any braces, artificial limbs or other surgical and 
medical appliances.  
(c)  Feeding  – the ability to feed oneself after the food has been prepared and 
made available.  
(d)  Toileting  – the ability to use the lavatory or manage bowel and bladder 
function through the use of protective un dergarments (e.g. diapers) or 
surgical appliances (e.g. urinary catheters) if appropriate.  
(e) Mobility  – the ability to move indoors from room to room on level 
surfaces.  
Washing  
Dressing  
Feeding  
Mobility  
Transferring  
Toileting  
Activities of Daily  Living (ADLs)  

9. Part II Healthcare Financing  
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                    207  
(f)  Transferring – the ability to move from a bed to an upright chair or 
wheelchair,  and vice versa.  
 
A3. Meets The Deferment Period Requirement  
 
6.11 There is a deferment period of 90 days starting from the claim date, i.e.  the date 
that the claim application is received by the AIC. If the insured is still disabled 
after this period, he will then be eligible for the benefit, provided that he satisfies 
the other conditions as specified in the policy. If he recovers from the d isability 
within the period, then no benefits are payable.  
 
6.12 However, the deferment period will not apply if the insured suffers a relapse 
from the same cause  within 180 days of recovery, provided that  he has been 
disabled for at least 90 days during the first disability.  
 
B. How To Make A Claim Under ElderShield?  
 
6.13 To make a claim, the insured needs to complete a claim form. In the event that 
he is not able to complete it on his own, his immediate family member or 
caregiver may do so on his behalf.  
 
6.14 Next, he has to make an appointment with an MOH -accredited severe disability 
assessor to have a disability assessment done. The assessor will then complete 
the assessment form and return it to the insurer for processing.  The list of 
accredited assessors can be found on the Agency for Integrated Care (AIC)’s 
website.  
 
6.15 It will cost S$ 100 for an assessment at the assessor’s clinic, and S$ 250 if the 
insured requires the assessor to make a house call. The fees for the initial or 
subsequent assessments will be reimbursed to the insured,  by the insurer , if 
the claim is assessed to be payable.  
 
C. How Are ElderShield Benefits Paid?  
 
6.16 As mentioned earlier, the ElderShield benefits are payable on a monthly basis. 
The premium under the policy will be waived during the benefit payout period. 
If an insured recovers from his disability, the monthly cash payout will stop and 
the premium payme nt will re -commence.


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The premium under the policy will be waived during the benefit payout period. 
If an insured recovers from his disability, the monthly cash payout will stop and 
the premium payme nt will re -commence. However, if he becomes disabled 
again some years later, he can still make a claim under his policy, as long as he 
has not claimed more than 60 months or 72 months in total, depending on the 
ElderShield plan under which the insured is c overed. The cash payout under 
this scheme is not tied to institutional care, and can be used to pay for any 
expenses, such as home nursing services, nursing home stay, day 
rehabilitation, medical bills, or household expenses, etc.  
 
  


Health Insurance   
 
208 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] D. Non-Forfeiture Featur e 
 
6.17 ElderShield premiums are pre -funded. This enables the policy to acquire a 
reserve. The accumulated reserve enables the insured to enjoy reduced benefits 
(i.e. the policy will be converted into a paid -up policy) if he decides to stop 
paying his premiums after the policy has been in force for a number of years.  
 
6.18 For example, an insured who joins ElderShield  at the age of 40 years will be 
eligible for a reduced benefit of around S$100 per month if he decides to stop 
paying his premiums 11 years after the policy has been in force.  
 
E. Other Key Features Of ElderShield  
 
6.19 The other key features of the ElderShield scheme are described below : 
(a) It is guaranteed renewability on an annual basis.  
(b) It provides worldwide coverage.  
(c) It has minimum (i.e. 40 years old) and maximum entry age (i.e. 64 years 
old).  
(d) A grace period of 75 days is allowed for payment of the overdue 
premiums.  
(e) Reinstatement of the policy is allowed within 180 days from the expiry of 
the grace period, subject to evidence of insurability at the insured’s 
expense and payment of the overdue premiums with interest.  
(f) The insurer has the right to appoint an assessor to examine the insured 
periodically.  
(g) Where the insured is overseas at the time of a claim, the insurer has the 
right to commute the benefit payments to a single payment reflecting the 
present value  of future benefit payments, or withhold the claim payment 
if it is unable to assess the claim after having made reasonable attempts 
to do so.  
(h) There is no cash surrender value.  
(i) There is a free -look period of 60 days from the policy commencement date 
during  which the insured may cancel his policy and  receive a full refund 
of the premiums  paid. 
 
F. Exclusions  
 
6.20 The ElderShield  policy does not cover any disability arising directly or 
indirectly, wholly or partly, from any one of the following occurrences:  
(a) self-inflicted injury , suicide  or attempted suicide ; 
(b) alcoholism or drug addiction ; or 
(c) war, whether declared or undeclared.  
 
6.21 CPF members who are  suffering from pre -existing disabilities , will not be 
covered under ElderShield.   
 

9. Part II Healthcare Financing  
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                    209  
G. Termination Of Cover  
 
6.22 The cover under the ElderShield  policy will be terminated upon the happening 
of any one of the following events:  
(a) expiry of the grace period if the ElderShield policy is not eligible for the 
non-forfeiture benefit (i.e. it has been in force for too short a period for it 
to acquire suffic ient reserves to be converted into a paid -up policy);  
(b) death of the insured;  
(c) date in which the last benefit payment has been received; or  
(d) date in which the written notice from the insured to cancel the policy is 
received by the insurer (if the policy does not have sufficient reserves, it 
will not be converted into a paid -up policy).  
 
H. Government Administration of ElderShield  
 
6.23 From 1 November 2021, the Government has taken over the administration of 
ElderShield from private insurers (Singlife with Aviva,  Great Eastern Life 
Assurance Co Ltd, and  Income Insurance Limited ). This allow ed ElderShield 
policyholders to upgrade to CareShield  Life more smoothly, and benefit from 
improvements to the claims assessment process that is being  implemented for 
CareShield Life.


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This allow ed ElderShield 
policyholders to upgrade to CareShield  Life more smoothly, and benefit from 
improvements to the claims assessment process that is being  implemented for 
CareShield Life.  
 
6.24 ElderShield policyholders that did not upgrad e to CareShield Life remain s 
covered by their existing ElderShield policies. T he Government administer s the 
ElderShield scheme on a not -for-profit basis. In the event that the actual claims 
experience turns out better than expected, there will continue to be premium 
rebates for ElderShield policyholders.  
 
6.25 Holders of ElderShield Supplements were not  affected. They continue to be 
served by their existing ElderShield Supplement insurers.  
 
6.26 With the launch of CareShield Life for existing cohorts on 6 November 2021, 
ElderShield no longer accepted new applications.  
 
  

Health Insurance   
 
210 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] 7.  CARESHIELD LIFE AND CARESHIELD LIFE SUPPLEMENTS  
 
7.1 CareShield Life was introduced in 2020, as an enhancement of ElderShield and 
is administered by the Government. As Singapore’s population ages and more 
people need long -term care, the role of risk -pooling via insurance was 
strengthened to help Singaporeans better prepare for their long -term care 
needs.  
 
7.2 CareShield Life provides worldwide coverage with lifetime payouts . 
Singaporeans will continue to be covered for life once they have completed 
paying all their premiums, which will happen in the year they turn age 67 or 10 
years after they join the scheme, whichever is later. Regardless of the place of 
residence, Singapo reans will remain covered, and be able to make a claim and 
receive payouts, if they are severely disabled and continue to pay their 
premiums.  
 
7.3 In order to make a claim, the insured  need s to be assessed by a  MOH -accredited 
severe disability assessor  as bein g unable to perform at least  three out of the 
six Activities of Daily Living (ADLs).  
 
7.4 CareShield  Life is administered by the Government on a not -for-profit basis, 
and offers:  
▪ better protection and higher payouts that increase over time, so that 
claimants c an better afford their basic long -term care needs;  
▪ protection for life;  
 
7.5 To ensure that no one will lose CareShield Life coverage due to genuine inability 
to pay, the Government provides the following premium subsidies and support:  
▪ Means -tested premium s ubsidies of up to 30% of premiums of CareShield 
Life, to help lower - to middle -income households.  
▪ Participation incentives of up to $2,500 for Singapore Citizens, if they join 
CareShield Life by 31 December 2023, to encourage those born in 1979 or 
earlier to join CareShield Life.  
▪ Additional participation incentives of $1,500 for Merdeka and Pioneer 
Generation citizens if they join CareShield Life by 31 December 2023.  
▪ Additional Premium Support for Singaporeans who are unable to pay their 
CareShield Life pre miums even after premium subsidies, so that no one will 
lose coverage under CareShield Life due to genuine inability to pay 
premiums.  
 
7.6 ElderShield  became a closed scheme from 1 August 2021. However, existing 
ElderShield300 and ElderShield400 policyholders can continue participating in 
the ElderShield scheme with no change to their benefits and coverage, unless 
they choose to join CareShield Life.  
 
7.7 It is important to note that any CareShield Life policyholder who wishes to 
obtain higher long -term care insurance coverage can also purchase 
Supplements . Supplements are plans which complement one’s basic 

9. Part II Healthcare Financing  
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                    211  
CareShield  Life plan by offering additional benefits, such as higher monthly 
payout amounts, which enhances the coverage.  
 
7.8 An insured  must have a CareShield Life or ElderShield policy in order to 
purchase a Supplement (might vary by insurer). Premiums for Supplement s can 
be paid using MediSave (up to a limit of S$600 per insured per calendar year) 
and/or by cash. As CareShield Life and Supplements are structured as stand -
alone policies, claims can be made under both policies if the insured fulfils the 
claim eligibili ty criteria.


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As CareShield Life and Supplements are structured as stand -
alone policies, claims can be made under both policies if the insured fulfils the 
claim eligibili ty criteria. The Supplement plans are currently only offered by the 
three insurers (Great Eastern, Income Insurance Limited , Singlife with Aviva) 
who were previously administering ElderShield.  
 
A. Coverage  
 
7.9 For Singapore Citizens and SPRs born in 1980 or later, CareShield Life is 
compulsory. There is no need to apply for CareShield Life. They will be 
automatically covered on their 30th birthday or when the scheme was launched 
in October 2020 , whichever is lat er, even if they have pre -existing disabilities. 
The following are worth noting:  
▪ There was a one -time enrollment of Singapore Citizens and SPRs born 
between 1980 and 1989 (i.e. age 31 to 40 in 2020).  
▪ Similarly,  Singapore Citizens and SPRs  born in 1980 or later  will be 
automatically covered under CareShield Life  regardless of their disability 
status . 
 
7.10 For Singapore Citizens and SPRs born in 1979 or before , joining CareShield Life 
is optional. They can choose to apply to join CareShield Lif e from 6 November 
2021 onwards as long as they do not have any pre -existing severe disability. 
They can still join the scheme if they have pre -existing conditions (e.g. diabetes, 
hypertension). There is no age limit to join CareShield Life. However, once t hey 
join CareShield Life, they will not be able to leave the scheme after the 60 -day 
free look period expires. The following are worth noting:  
▪ To increase the convenience of joining, Singapore Citizens and SPRs born 
between 1970 and 1979, and who are insur ed under ElderShield400, had 
been auto -enrolled into CareShield Life from 1 December 2021. They have 
up to 31 December 2023 to opt -out of the scheme. If they opt -out, they will 
be reinstated onto ElderShield400.  
▪ Unlike existing Singapore Citizens and SPRs born in 1979 or before, new 
Singapore Citizens and SPRs will be mandated to join CareShield Life, as 
long as they do not have any pre -existing severe disability.  
 
B. Benefits Under CareShield Life  
 
7.11 CareShield Life feature s higher payouts that increase over time with no cap on 
payout duration, to provide better protection against the uncertainty of long -
term care costs in the event of severe disability. The following points are worth 
noting:  
▪ Lifetime cash payouts are given for as long as the policyholder is severely 
disabled  

Health Insurance   
 
212 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] ▪ Payouts increase  annually  until age 67 or when a  successful  claim is made, 
whichever is earlier , with payouts starting at S$600 per month in 2020  
   
7.12 For more details on the estimated monthly payouts appli cable, please refer to 
https://www.moh.gov.sg/careshieldlife/about -careshield -life  
 
C. CareShield Life Premiums  
 
7.13 The CareShield  Life scheme makes use of pre -funded premiums i.e.  the insured 
CPF members pay more than the cost of their health risk, while they are 
younger, to cover for the higher risk in their later years. Insured CPF members 
will pay premiums until the year they turn age 67 or  for 10 years, whichever is 
longer , but will remain insured for life, even after completion of the premium 
payments. Premiums are  not guaranteed  and are subject to review. The 
premiums are fully payable by MediSave . 
 
7.14 For Singapore Residents born 1980 or later (future cohorts), premiums are paid  
from the age of enrolment until age 67. Premiums will increase over time, to 
support payout increases. For the first five years of CareShield Life’s 
implementation, payouts and premiums will both increase by 2% per year.  
Beyond 2025, an independent CareSh ield Life council will advise the 
Government on premium and payout adjustments based on actuarially sound 
adjustment framework.  
 
7.15 Singapore Residents born in 1979 or earlier (existing cohorts) will pay a base 
premium.


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7.15 Singapore Residents born in 1979 or earlier (existing cohorts) will pay a base 
premium. The bas e premium is generally paid from the age of enrolment until 
age 67, but Singapore residents who join at age 59 or older in 2021 will be able 
to spread their catch -up premiums over 10 years, beyond age 67. Other points 
in this regard are as follows:  
 
▪ Base premiums will increase over t ime to support payout increases, until 
the year policyholders turn 67. Premiums and payouts do not increase after 
the year policyholders turn 67. For the first five years of CareShield Life’s 
implementation, payouts and base premiums for policyholders age 67 and 
below will both increase by 2% per year.  
 
▪ ElderShield 400 policyholders  who have been consistently on an 
ElderShield policy (i.e. never opted out, or upgraded from ElderShield 300 
to ElderShield 400 in 2007 when they had the chance to) will only pay  the 
base premium each year, if they join CareShield Life in 2021.   
 
▪ Other groups, including existing ElderShield 300 policyholders, existing 
ElderShield 400 policyholders who joined later than 2021 as well as those 
not insured under ElderShield, will need  to pay an additional catch -up 
component (which differs for each group), as they would not have paid as 
much premiums as those in their same cohort who are insured under the 
ElderShield 400 scheme and joined in 2021. The catch -up component will 
be paid ove r 10 years and will remain flat. 
 
The diagram below further illustrates the points highlighted above.  

9. Part II Healthcare Financing  
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                    213  
 
 
7.16 Singapore Residents may obtain estimates of the premiums and subsidies 
through the online premium calculator, available at www.careshieldlife.sg .  
 
7.17 CareShield Life premiums can be fully payable by MediSave. Subs idies and 
support are available to make sure the premiums remain affordable, so the 
insured does not need to worry about losing coverage if he/she has an genuine 
inability to pay premiums.  
 
D. Pioneer and Merdeka Generation Incentives  
 
7.18 Pioneer  and Merdeka Generation seniors who join CareShield Life by 31 Dec 
2023, will receive additional Pioneer Merdeka Generation incentives of S$1,500, 
spread over 10 years (total incentives of S$4,000 for MG and PG members).  
 
7.19 Pioneer Generation Seniors refer to living Singapore Citizens born on or before 
31 December 1949 and obtained citizenship on or before 31 December 1986. 
Merdeka Generation Seniors refers to : 
(i) living Singapore Citizens who were born from 1 January 1950 to 31  
December 1959 and had obtained citizenship on or before 31 December 
1996; and  
(ii) those who were born on or before 31 December 1949, had obtained 
citizenship on or before 31 December 1996 and  do not receive the Pioneer 
Generation Package.  
 
  
Note: Existing Cohorts who join CareShield Life at age of 59 or older will end their premium payment after age 67 as 
they will have a 10 -year premium payment term.  
Diagram not drawn to scale  Illustration of Base Premium and Catch -up Component Payable b y Singapore Residents from Existing 
Cohorts who join CareShield Life  

Health Insurance   
 
214 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] E. Eligibility Criteria for Payment of CareShield Life  Benefits   
 
7.20 The eligibility criteria for CareShield Life benefits is similar to that of 
ElderShield . 
 
E1. Unable To Perform The Specified Number Of Activities Of Daily Living As 
Defined   
 
7.21 CareShield Life will pay a monthly benefit of at least S$600 for as long as the 
insured is severely disabled. It pays the benefits if the insured is unable to 
perform at least three of the six Activities of Daily Living (ADLs)  as defined .   
 
E2. Meets The Deferment Period Requirement  
 
7.22 There may be  a deferment period of 90 days starting from the claim date, i.e.  
the date that the claim application is received by the AIC. If the insured is still 
disabled after this period, he will then be eligible for the benefit, provided that 
he satisfies the other conditions as specified in the policy.


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the date that the claim application is received by the AIC. If the insured is still 
disabled after this period, he will then be eligible for the benefit, provided that 
he satisfies the other conditions as specified in the policy.  
 
F. How to Make a Claim U nder CareShield Life?  
 
7.23 To make a claim, the insured needs to submit a claim application to the A gency 
of Integrated Care  (AIC) . In the event that he is not able to complete it on his 
own e.g. if he lacks mental capacity , his donee/deputy/ immediate  family 
member or caregiver may do so on his behalf.  
 
7.24 Next, he has to make an appointment with an MOH -accredited severe disability 
assessor to have a disability assessment done. The assessor will then complete 
the assessment and submit it to AIC directly . The lis t of accredited assessors 
can be found on AIC’s website.  
 
7.25 The fees for the first CareShield Life disability assessment are waived 
regardless of whether the claim is eventually assessed to be payable. 
Thereafter, the fees for subsequent assessments will only be reimbursed to the 
insured if the claim is assessed to be payable. More details on the applicable 
assessment fees can be found on AIC’s website.  
 
G. Other Key Features of CareShield Life  
 
7.26 The other key features of the CareShield Life scheme are stated  below : 
(a) It is guaranteed renewab le on an annual basis.  
(b) It provides worldwide coverage.  
(c) It has a minimum entry age of 30 years old, but no maximum entry age.  
(d) The CareShield Life policy will be terminated if the insured is no longer a 
Singapore Citizen or SPR.  
(e) There is no cash surrender value . 
 

9. Part II Healthcare Financing  
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                    215  
8. OTHER HEALTHCARE FINANCING SCHEMES SET UP BY THE SINGAPORE 
GOVERNMENT  
 
8.1 Besides the Government subsidies, MediSave  and insurance schemes as 
discussed above, the Government has also put in place a number of other 
schemes, to help Pioneers  not to mention  poor and needy Singaporeans. The 
schemes are as follows:  
(a) Pioneer Generation  Package;  
(b) Merdeka Generation Package;  
(c) Interim Disability Assistance Programme For The Elderly (IDAPE ); 
(d) ElderFund and 
(e) Medifund.  
(f) COVID -19 Medical Bills  
 
A. Pioneer Generation Package   
 
8.2 The Government introduced the Pioneer Generation Package  in 2014  to honour 
and thank the pioneers for their significant contributions in the early years of 
nation -building.   
 
8.3 The “Pioneer Generation” refers to living Singaporeans who meet two criteria, 
namely:  
(a) aged 16 years and above in 1965 (born on or before 31 December  1949, 
which also means that they were aged 65 years and above in 2014); and  
(b) obtained citizenship on or before 31 December 1986.  
 
8.4 The package  provides the benefits (as described below) which the Pioneer 
Generation will enjoy for life.  
 
A1. Outpatient Care  
 
(a) Additional 50% off remaining bill for subsidised services and medications  
at polyclinics and Specialist Outpatient Clinics.  
(b) Special subsidies at participating GP and dental clinics under CHAS .  
(c) Cash of S$1,200 a year for those with moderate to severe functional 
disabilities under the Pioneer Generation Disability Assistance Scheme . 
 
A2. MediShield Life  
 
8.5 Pioneers  will receive Pioneer Generation subsidies for MediShield Life .  
 
A3. MediSave  Top-ups 
 
8.6 All Pioneers will receive annual MediSave top -ups for life, which range from 
$250 -$900 depending on birth cohort. These top -ups can be used to further 
offset premiums for Med iShield Life, ElderShield, and CareShield Life. Older 
Pioneers with serious pre -existing conditions will receive additional MediSave 

Health Insurance   
 
216 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] top-ups of $50 -$200 from 2021 -2025, to help with their higher MediShield Life 
premiums.   
 
A4.


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A4. Pioneer Generation Disability Assistance Scheme  
 
8.7 This scheme is f or Pioneers who permanently need assistance in at least three 
of thes e ADLs :  
▪ Eating  
▪ Bathing  
▪ Dressing  
▪ Transferring  
▪ Toileting  
▪ Walking or moving around  
 
8.8 Lifelong cash assistance of S$100 each month  is provided  to help Pioneers with 
their care expenses.  
 
A5. CareShield Life  
 
8.9 Pioneers will receive a participation incentive if they join CareShield Life within 
the first two years of scheme launch . Do refer to earlier s ection  of this Chapter 
for more information on this.  
 
B. Merdeka Generation Package   
 
8.10 The Government introduced the Merdeka Generation Package (MGP) in 2019 to 
honour and thank our Merdeka Generation (MG) for their contributions. The 
MGP supports the aspirations of MG seniors in their silver years by helping 
them to stay active and healthy, and providing them better peace of mind over 
future healthcare costs.  
 
8.11 The “Merdeka  Generation” re fers to living Singaporeans who:  
(a) were born from 1 January 1950 to 31 December 1959, and  
(b) had obtained citizenship on or before 31 December 1996.  
 
8.12 The MGP is also extended to living Singaporeans who:  
(a) were born on or before 31 December 1949,  
(b) had obtained citizenship on or before 31 December 1996, and  
(c) do not receive the Pioneer Generation Package.  
 
8.13 The package comprises the following benefits : 
 
B1. Passion Silver Card Top-Ups 
 
8.14 MG seniors  receive a one -time S$100 top -up to their PAssion Silver cards.  They 
can use this to pay for use on active ageing programmes, public transport , 
entries to swimming pools and other purchases at all EZ -Link merchants.  

9. Part II Healthcare Financing  
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                    217  
B2. MediSave Top-Ups 
 
8.15 MG seniors receive a MediSave top -up of $200 per year for five years, from 2019 
to 2023.  This will help them save more for their healthcare needs. This is on top 
of the GST Voucher – MediSave top -ups that eligible seniors aged 65 and above 
receive every year.  
 
B3. Outpatient Care 
 
(a) Additional 25% off remaining bill for subsidised services and medications  
at polyclinics and Specialist Outpatient Clinics .  
(b) Special subsidies at participating GP and dental clinics under CHAS .  
 
B4. MediShield Life  
 
8.16 MG seniors receive Additional MediShield Life Premium Subsidies.   
 
B5. CareShield Life  
 
8.17 MG seniors will receive CareShield Life Additional Participation Incentives i.e. a 
participation incentive if they join CareShield Life within the first two years of 
scheme launch . Do refer to earlier section of this Chapter for more information 
on this.  
 
C. Interim Disability Assistance Programme For The Elderly (IDAPE)  
 
8.18 IDAPE was launched by the Government to take care of Singaporeans who were 
not eligible to join the ElderShield sch eme, when it was launched in September 
2002, either because they exceeded the maximum entry age or they had  a pre-
existing disability.  It is aimed at helping this group of people to cope with their 
medical expenses, in the event that they suffer any severe  disability. Individuals 
covered under the scheme need not pay any premiums.  
 
8.19 A Singaporean will qualify for IDAPE if:  
 
▪ He is unable to perform three  or more of the 6 Activities of Daily Living (ADL) 
- washing, feeding, dressing, toileting, mobility and transferring.  
 
▪ He is a Singapore citizen born before 30 September 1932 OR born between 
1 October 1932 and 30 September 1962 (both dates inclusive) but with pre -
existing disabilities as at 30 September 2002.  
 
▪ His per capita household monthly income is $2,800 or less OR he has no 
household income and is living in a residence with Annual Value of $13,000 
and below.


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▪ His per capita household monthly income is $2,800 or less OR he has no 
household income and is living in a residence with Annual Value of $13,000 
and below.  
 
  

Health Insurance   
 
218 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] 8.20 The payment under the scheme is depende nt on the individual’s per capita 
household income as shown in Table 9.4. 
 
Table 9.4: IDAPE Payout  
 
Per Capita Household Income * IDAPE Payout  
(With Effect From 1 July 2013)  
(a) S$0 to S$2,000  (a) S$250 per month for up to 72 months  
(b) S$2,001  to S$2,800 (b) S$150 per month for up to 72 months  
*An IDAPE applicant from a household with no income will qualify for the S$250 monthly 
payout if the annual value of his place of residence is S$13,000 or lower.  
 
Source: MOH Website   
 
8.21 IDAPE is currently administered by the Agency for Integrated Care (AIC).  Other 
than the fact that the payout is lower than the ElderShield scheme, the definition 
of disability and the claim procedures are the same as those for ElderShield with 
the followin g exceptions . 
(a) those making claims under IDAPE will be subject to a means testing 
administered by the Ministry of Health Holdings (MOHH); and  
(b) the recipient of the payout will need to pay a nominal fee of S$10 for a clinic 
assessment (or S$40 if assessment i s done at home) for each assessment 
in the event of a claim. The rest of the fees are subsidised by the 
Government.  
 
8.22 As you can see, the payouts under ElderShield and IDAPE are basic and limited 
to 72 months.Those on Eldershield  can consider purchasing a dditional Long -
Term Care Insurance coverage, if they wish to have higher payouts or longer 
payout periods, and can afford the premiums for the extra coverage. Existing and 
prospective CareShield Life clients can do likewise to purchase additional Long -
Term  Care Insurance coverage, if they wish to have higher payouts.  
 
D. ElderFund  
 
8.23 ElderFund  is a discretionary assistance scheme launched on 31 January 2020.  It 
is targeted at severely disabled lower -income Singapore Citizens aged 30 and 
older, who are not able to benefit from  CareShield Life , ElderShield , and 
the Interim Disability Assistance Programme for the Elderly  (IDAPE), have 
low MediSave  balanc es and have inadequate personal savings to meet their 
long -term care needs.   Eligible Singapore Citizens can receive up to $250 cash 
per month for as long as they remain eligible, and meet the terms and conditions 
needed for receipt of payment.  
 
  

9. Part II Healthcare Financing  
Copyright reserved by the Singapore College of Insurance Limited [Version  1.4]                    219  
E.  Medi Fund  
 
8.24 MediFund is an endowment fund set up by the Government. It provides a safety 
net for needy Singaporeans who face difficulties paying for their remaining 
healthcare bills after Government subsidies, insurance and MediSave.  
 
8.25 MediFund Silver and MediFun d Junior are carved out from MediFund to provide 
more targeted assistance for the needy elderly and children respectively.  
 
8.26 As an endowment fund, interest income generated from the capital sum are 
allocated to MediFund -approved healthcare institutions, for them to assist with 
the healthcare bill payments of needy patients. Every MediFund -approved 
institution has an independent MediFund Committee to consider and approve 
applications, and decide on the appropriate quantum of assistance.  
 
8.27 To apply for MediFund assistance, one must:  
 
▪ be a Singapore citizen;  
▪ be a subsidised patient;  
▪ have received or require treatment from a MediFund -approved institution; 
and 
▪ be having difficulties paying for his remaining healthcare bills after 
Government subsidies and other means including MediShield Life and 
MediSave.  
 
8.28 The patient’s application will  be assessed holistically by the medical social 
workers and the MediFund Committees, taking into consideration his and his 
family’s financial, health and social circumstances.  
 
F.  COVID -19 Medical Bills1 
 
8.29 In Singapore, healthcare support in the form of S+3Ms (Government Subsidies, 
MediSave, MediShield Life and MediFund) are extended widely  to all 
Singaporeans.


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Notwithstanding  such support , as part of the pandemic response, 
COVID -19 treatments have be en provided at a very low cost or free of charge, 
going beyond  the scope of  the regular S+3Ms. As life reverts to normal and 
COVID -19 becomes endemic, the need to  progressively reduce such subsidies 
and support is obvious . It is therefore not surprising to witness the current 
gradua l reverting to pre-COVID -19   S+3Ms healthcare financing frameworks  
underpinning the Singapore healthcare system . 
 
8.30 Since February 2020, more than 1,000 Public Health Preparedness Clinics (PHPCs) 
have been activated to provide subsidised care for patients with respiratory 
infection sym ptoms, whether due to COVID -19 or not. Singapore residents pay a 
flat subsidised rate of $10 and seniors from the Pioneer Generation and Merdeka 
Generation pay a lower rate of $5.  
 
 
1 https://www.moh.gov.sg/news -highlights/details/further -rationalisation -of-smms -boosting -vaccinations -
and-updates -to-covid -19-subsidies


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1 https://www.moh.gov.sg/news -highlights/details/further -rationalisation -of-smms -boosting -vaccinations -
and-updates -to-covid -19-subsidies  


Health Insurance   
 
220 Copyright reserved by the Singapore College of Insurance Limited [Version  1.4] 8.31 From  1 July 2022, subsidies at PHPCs and polyclinics for the treatment of 
respiratory infections have  reverted to pre -COVID -19 levels. The $10/$5 fee  no 
longer appl ies, but Singaporeans  continue  enjoy ing prevailing subsidies under 
the Community Health Assist Scheme (CHAS) at CHAS General Practitione r (GP) 
clinics.  
 
8.32 The above does not affect ART and Polymerase Chain Reaction (PCR) tests, 
where PHPCs and polyclinics will continue to provide government -funded swabs 
to eligible symptomatic individuals at no charge.  
 
8.33 Currently, individuals under Protocol 2, i.e. mildly symptomatic, low risk, and 
recovering from home, and who requested for telemedicine care enjoy  full 
subsidy.  
 
8.34 In line with the above change for PHPCs, from  1 July 2022,  the government has 
reverted  to pre-COVID -19  subsidy levels . Full subsidy for  telemedicine will cease, 
but Singaporeans will continue to enjoy CHAS subsidies if they visit a CHAS GP 
clinic for treatment. Individuals under Protocol 1, i.e. those at high medical risk 
or with se vere symptoms but  are discharged for home recovery and under 
telemedicine surveillance, will continue to enjoy fully subsidised telemedicine 
care.  
 
8.35 Currently, Singapore Citizens/ Permanent Residents /Long -Term Pass Holders 
(SC/PR/LTPHs) w ho seek emergency treatment for COVID -19 in Emergency 
Departments (ED) of public acute hospitals do not have to pay any ED charges if 
they are fully vaccinated or  certified to be medically ineligible for vaccination.  
 
8.36 From  1 July 2022,  this will no longer apply to those who do not require admission 
after visiting the ED. Those who are assessed to require hospital isation  or 
undergo treatment at a  COVID -19 Treatment Facility (CTF)  will continue to have 
their ED, inpatient and/or CTF bills fully subsidised by the government, if they are 
fully vaccinated or certified to be medically ineligible for vaccination. This will 
help MOH manage the demand for ED services  and cater to those who need 
them.  
 
8.37 To understand more about the charging polic ies for SC/PR/LTPHs travelers  who 
are subjected to General Travel Category or Restricted Category border 
measures, please refer to:   
https://www.moh.gov.sg/news -highlights/details/easing -of-community -smms -
and-border -measures  

28
HEALTHCARE FINANCING PART I & IICHAPTER
09
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Singapore government 
subsidies • Government provides funding to public healthcare institutions (e.g. public 
hospitals, national specialty centres and polyclinics), as well as selected private 
clinics and voluntary welfare organisations (VWOs).
• Means-test is used to target subsidies, so that needy patients can receive 
more help; lower-income patients receive more subsidies than higher-income 
patients.
Main components of 
Singapore’s Healthcare 
Financing System
MediSave • National healthcare savings scheme in Singapore under the Central Provident 
Board (CPF) umbrella.
• Contributions to the Medisave Account (MA) are subject to a maximum amount, 
known as the Basic Healthcare Sum (BHS). The BHS is designed to be enough 
for a CPF member’s basic, subsidised healthcare needs in his old age. Hence, 
amounts in the MA up to the BHS cannot be withdrawn as cash.
• Amounts above the BHS will flow to the CPF member’s Special or Retirement 
Accounts to boost his monthly payouts. If the CPF member has already met his 
Full Retirement Sum, the amounts will flow to his Ordinary Account, and can be 
withdrawn as cash from the age of 55 years.
• Can be used to pay for the CPF member’s medical expenses at all accredited 
institutions, in both the public and private sector.
• Can also be used to pay for medical expenses of the CPF member’s approved 
dependents, namely his spouse, children, parents, siblings, and grandparents. If 
paying for a sibling or grandparent, the patient must be a Singapore Citizen or 
Singapore Permanent Resident (SPR).


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29
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Uses of MediSave Account
How much Medisave can 
be usedThe use of MediSave is subject to:
• Withdrawal Limit.
• Additional Withdrawal Limit (AWL).
Payments via MediSave are allowed in all public healthcare institutions, as well as 
approved private hospitals and medical institutions
Distribution Of MediSave 
Upon Demise• If a patient was hospitalised just before death and had authorised the use of his 
MediSave to pay for his medical bill, his MediSave balance would be used in full, 
without being subject to the existing MediSave withdrawal limits, to pay for his 
last inpatient medical bill.
• If the patient had not authorised the use of his MediSave before his demise, his 
immediate family member (spouse, parent, or child who is aged 21 years and 
above), or donee or deputy can also do so for the last inpatient medical bill, 
provided that it has not been paid out to the patient’s nominated beneficiaries.
• In the event that the patient does not have any immediate family member, 
or donee or deputy to authorise the use of the patient’s MediSave, a relative 
who has been taking care of the patient may also write to MOH through the 
hospital to seek approval for the relative to authorise the withdrawal of patient’s 
MediSave, to pay for the last inpatient medical bill.
• Remaining MediSave balance, after the payment of the last medical bill, would 
be distributed to the nominated beneficiaries of the patient’s CPF account if a 
nomination was made before his death. If there was no nomination made, the 
balance in the deceased patient’s MA would be distributed by the Public Trustee 
to his family members under the intestacy laws for non-Muslims, or the Muslim 
inheritance law for Muslims.Uses of Medisave Items that can be paid using MediSave
Outpatient 
TreatmentsSelected outpatient treatments such as:
• Approved chronic conditions under the chronic 
disease management programme
• Vaccinations
• Health screenings
Inpatient Treatments Inpatient care  which includes:
• Inpatient episodes 
• Inpatient psychiatric episodes
• Day surgery
• Assisted Conception Procedures
Long-Term Care Long-Term Care treatments which include: 
• Rehabilitative care
• Palliative care
• Disability care
Insurance Premiums Premium payments of: 
• MediShield Life
• ElderShield/CareShield Life
which can be fully paid with MediSave
• Integrated Shield Plans and ElderShield/CareShield 
Life supplements
which are subject to withdrawal limits periodically 
reviewed by MOH

30
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
MediShield Life • Basic healthcare insurance scheme.
• Covers all Singapore Citizens and Singapore Permanent Residents against large 
medical bills for life, regardless of age or health conditions.
• The claim limits are sized to cover subsidised bills incurred for hospitalisation in 
class B2/C wards, day surgery, and selected costly outpatient treatments (e.g., 
dialysis and chemotherapy) in the public hospitals.  
• However, MediShield Life benefits are designed based on Class B2/C bills, so 
as to keep premiums affordable. Those who would like additional coverage in 
Class A/B1 wards or private hospitals may consider buying Integrated Shield 
Plans (IP).
• No need to apply for MediShield Life. All SCs and PRs are automatically covered 
under MediShield Life from 1 Nov 2015. New SCs are covered from birth or 
from the day they attain citizenship. PRs are covered from the day they attain 
permanent residency.
• MediShield Life premiums may be fully paid from MediSave.
• Please refer to the Study Text for a list of treatment items, procedures, 
conditions, activities which are not covered by MediShield Life and cannot be 
claimed.
MediShield Life Premiums • Actuarially priced based on the health risks and expected healthcare utilisation 
of each age group so that each age group’s payouts are broadly supported by 
their own premiums.
• Those with pre-existing medical conditions can enjoy coverage for their 
conditions. Only those with serious pre-existing medical conditions listed in the 
MOH website need to pay a nominal Additional Premium of 30% for the first 10 
years, in addition to the standard MediShield Life premiums.
• One can pay premiums from own MediSave, or family members may pay one’s 
premium using their MediSave. Parents may also tap on the MediSave Grant for 
newborns to pay for their child’s MediShield Life premiums.
How Are MediShield Life 
Claim Payouts Computed?• Pays on a reimbursement basis, subject to the claim limits imposed on the 
covered medical expenses, as well as deductible, co-insurance and pro-ration 
factors.


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How Are MediShield Life 
Claim Payouts Computed?• Pays on a reimbursement basis, subject to the claim limits imposed on the 
covered medical expenses, as well as deductible, co-insurance and pro-ration 
factors.
• The deductible is the fixed amount payable by the insured each policy year (the 
year following his policy renewal month), before the MediShield Life payout 
starts. The deductible is payable only once every policy year.
• Co-insurance is the patient’s share of the claimable amount which the insured 
will have to pay, along with the deductible.
Please refer to the Study Text for example of how the reimbursement under 
MediShield Life is arrived at.
Integrated Shield Plans Integrated Shield Plans (IPs) are MediSave-approved hospitalisation insurance plans 
made up of two parts. 
• MediShield Life component administered by the CPF Board. 
• An additional private insurance coverage component administered by approved 
private insurers, typically to cover Class A/B1 wards of public hospitals or 
private hospitals. 
No duplication of coverage between IPs and MediShield Life.

31
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Consideration on 
Integrated Shield Plans (IP)• With the different IPs available, it is necessary for the sellers of such plans to 
understand the different plans offered in the insurance market, and to advise 
their prospective clients, based on the needs and long-term affordability of each 
individual client’s position.
• As part of due diligence, clients should be informed of the key differences 
in premiums, benefits, exclusions, deductibles, co-insurance and other co-
payment features between the various IPs offered by their insurer, versus 
MediShield Life. There are different benefits provided in the IP policy, and plans 
can be “as charged” or “non -as-charged” (i.e. they have sub-limits imposed). 
Information provided should be easy to understand, unambiguous and clearly 
explained to help clients make an informed decision.
• Clients should consider if they would wish to stay in a private or subsidised 
ward in a public hospital, or in a private hospital, and if they wish to choose 
their own doctors.
• Clients should consider if they can afford their IP premiums in the long term as 
the policyholders may have to pay a substantial portion of their IP premiums in 
cash, especially at the older ages.
• Unlike MediShield Life which provides coverage for pre-existing medical 
conditions (with Additional Premiums for the first 10 years), the coverage for 
the private insurance component of the IP may be declined or imposed with 
exclusions for pre-existing conditions. The private insurance component may 
also have premium loading, arising from pre-existing conditions.
How MediSave can be used 
to meet a CPF member’s 
healthcare needs and buy 
approved Medical Expense 
Insurance?MediSave can be used to pay premiums for IPs, either in full or in part, depending 
on the age group and the IP plan type. From 1 November 2015, MediSave use for 
the additional private insurance component of the IP premiums is subject to the 
new Additional Withdrawal Limit (AWL). The AWL is set per insured person per 
policy year, as stated below:
• Age Next Birthday (ANB) 40 years and below: S$300 
• ANB 41 to 70 years: S$600
• ANB 71 years and above: S$900
How MediShield Life 
premiums are kept 
affordable?• Premium Subsidies for lower- to middle-income.
• Pioneer and Merdeka Generation Subsidies.
• COVID-19 Subsidies.
• Additional premium support.
How MediShield Life 
interacts with Integrated 
Shield Plans?MediShield Life Scheme Integrated Shield Plan (IP) 
It is administered by the CPF Board It is administered by private insurers, 
as approved by MOH.
Its coverage is sized for stays in Class 
B2/C wards of public hospitals.It provides for enhanced coverage 
beyond MediShield Life, with various 
plan types available for stays in private 
hospitals and/or Class A/B1 wards of 
public hospitals.
It covers all pre-existing conditions. Coverage for the private insurance 
component of the IP may be declined 
or imposed with exclusions and/or 
premium loading, arising from pre-
existing conditions.
There is no minimum or maximum age 
limit.It may have a minimum or maximum 
entry age limit.
There are sub-limits applicable. It may have sub-limits, although most 
do not have sub-limits.
MediShield Life premiums are fully 
payable by MediSave.MediShield Life component of the IP 
is fully payable by MediSave, while 
private insurance component of 
the IP is payable by MediSave up to 
Additional Withdrawal Limit, and the 
remainder is payable by cash.


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All Singapore Citizens and Permanent 
Residents are automatically covered 
for life. No application is required.Application to private insurers is 
required.
31

32
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Standard IP • “No frills” product targeted at covering large Class B1 ward hospital bills and 
selected outpatient treatments.
• Affordable option for Singapore Citizens and Permanent Residents who want 
additional coverage beyond MediShield Life and may find other higher coverage 
IPs too expensive.
Riders • Pay for the co-insurance and deductible portion of the IP, and may pay cash 
payouts upon hospitalisation.
Need for Co-Payments • Co-payment is an important principle in the design of healthcare insurance. It 
encourages policyholders and their doctors, to consider the necessity of the 
medical treatment and its cost, so that they can make an informed decision 
on the appropriate healthcare services. This encourages prudence and keeps 
healthcare cost, and health insurance premiums, affordable and sustainable in 
the long term.
Terminating or Switching 
IP/Switching Insurer• An IP policyholder who cannot afford, or does not wish to continue paying the 
premium for his IP, can  switch his plan to a lower coverage plan within the 
same insurer at any point in time, without additional underwriting involved. 
• He can also  terminate his IP at any point in time, and still be covered by 
MediShield Life which provides basic health insurance, regardless of any pre-
existing conditions.  
• If the person with an existing IP switches to a new IP with another insurer, 
Original IP with the previous insurer will be automatically terminated.
• Option to go back to the previous insurer within 30 days from the date of 
notification of termination from the previous insurer.
Risk-Loading by private 
insurers• MOH allows IP insurers to risk-load insured members with pre-existing 
conditions for the private insurance component of the IPs.
Benefits in having Pre-
Authorisation for IP• Insurers can assess the medical necessity and cost of treatment to ensure it is 
within the terms and conditions of the policy’s coverage.
• Patients will have a peace of mind in knowing that their procedure is within 
their insurance coverage; and
• Healthcare providers have better clarity on the type of procedures covered by 
insurance to better advise their patients prior to the actual procedure. 
Policyholders are thus encouraged to seek pre-authorisation for planned 
procedures as far as possible if the option is provided by the insurer.
Claims process of 
MediShield Life, Integrated 
Shield Plans, other Medical 
Expense Insurance and 
MediSaveAny insured CPF member who wishes to claim from his MediShield Life, IP and/or 
MediSave will need to complete the Medical Claims Authorisation Form to:
• Allow the hospital to claim from his insurer; and 
• Instruct the CPF Board to deduct from his MA to pay for his hospital bill, while 
the insurer settles the claim.
For any insured CPF member who wants to claim from MediShield Life, IP and/or 
MediSave, the hospital will submit the claim on his behalf through the MediClaim 
online system after he has been discharged.
If there is no pre-authorisation, the insured CPF member under an IP can approach 
the hospital to trigger a request for a Letter of Guarantee (LOG) from his insurer 
upon hospital admission. It is important that the insured CPF member understands 
that a LOG may not mean that the insurer will pay for the specified amount. To 
obtain assurance that their bill will be covered, the insured CPF member may wish 
to apply for pre-authorisation instead, if available.
For someone who is covered by his employer medical benefits or other private 
insurance plans, he will need to show his insurance card (provided by some insurers 
for certain Medical Expense Insurance plans) to the hospital admission staff. The 
hospital may fully or partially waive the deposit in such a case.
• Some hospitals will send the hospitalisation bill directly to the CPF member’s 
non-IP private insurer or employer. In other cases, the insured CPF member will 
have to submit the bill himself to the insurer. 

33
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Withdrawal Limits for 
Inpatient, Outpatient, 
Long-Term Care and 
Insurance PremiumsPlease refer to the Study Text for the full list.
MediShield Life Benefits Please refer to the Study Text for the full list.
ElderShield & ElderShield 
SupplementsElderShield is a long-term care insurance scheme launched in September 2002. It 
provides basic financial protection to those who need long-term care, especially 
during old age.
ElderShield Supplement plans complement the current ElderShield scheme, by 
offering additional benefits at different pricing levels which increase the insured’s 
coverage through:
• Increasing the monthly payout;
• Extending the payout period; or
• A combination of both.


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How ElderShield and 
ElderShield Supplements 
work?• To purchase and maintain an ElderShield Supplement, an insured must have an 
ElderShield policy.
• Premiums for ElderShield Supplement can be paid using MediSave (up to a limit 
of S$600 per insured per calendar year) and/or by cash.
• The ElderShield scheme will pay a monthly benefit of either S$300 up to 60 
months, or S$400 up to 72 months, depending on the type of the scheme in 
which the CPF member is covered.
Eligibility Criteria For 
Payment Of ElderShield 
benefits• Meets the waiting period requirement.
• Unable to perform the specified number of activities of daily living 
• Meets the deferment period requirement (If he recovers from the disability 
within the period, then no benefits are payable).
• Please also note on making a claim under ElderShield and how the benefits are 
paid.
Features of ElderShield • Non-forfeiture feature.
• Guaranteed renewability on an annual basis.
• Worldwide coverage.
• Minimum (i.e. 40 years old) and maximum entry age (i.e. 64 years old).
• Grace period of 75 days is allowed for payment of the overdue premiums.
• Reinstatement of the policy is allowed within 180 days from the expiry of the 
grace period, subject to evidence of insurability at the insured’s expense and 
payment of the overdue premiums with interest.
• Insurer has the right to appoint an assessor to examine the insured periodically.
• Where the insured is overseas at the time of a claim, the insurer has the right 
to commute the benefit payments to a single payment reflecting the present 
value of future benefit payments, or withhold the claim payment if it is unable 
to assess the claim after having made reasonable attempts to do so.
• No cash surrender value.
• Free-look period of 60 days from the policy commencement date during which 
the insured may cancel his policy, and receive a full refund of the premiums 
paid.

34
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Exclusions of ElderShield • Self-inflicted injury, suicide or attempted suicide;
• Alcoholism or drug addiction; or
• War, whether declared or undeclared.
• CPF members who are suffering from pre-existing disabilities, will not be 
covered under ElderShield.
Termination of cover for 
ElderShield• Expiry of the grace period if the ElderShield policy is not eligible for the non-
forfeiture benefit (i.e. it has been in force for too short a period for it to acquire 
sufficient reserves to be converted into a paid-up policy);
• Death of the insured;
• Date in which the last benefit payment has been received; or
• Date in which the written notice from the insured to cancel the policy is received 
by the insurer (if the policy does not have sufficient reserves, it will not be 
converted into a paid-up policy).
ElderShield to CareShield 
Life• ElderShield became a  closed scheme from 1 August 2021.
• The Government had taken over the ElderShield administration from 1 
November 2021.
• New cohorts born in 1980 or later were covered under CareShield Life from 1 
Oct 2020 but Singapore Citizens and SPRs born in 1979 or earlier could still opt 
in to the ElderShield scheme up till 1 Aug 2021 if they are below 65. 
• Existing ElderShield policyholders could continue to remain covered under the 
scheme with no changes to their coverage and benefits.
CareShield Life & 
CareShield Life 
SupplementsCareShield Life was introduced in 2020, as an enhancement of ElderShield and is 
administered by the Government on a not-for-profit basis, and offers;
• Better protection and higher payouts that increase over time, so that claimants 
can better afford their basic long-term care needs; and 
• Protection for life.
Any CareShield Life policyholder who wishes to obtain higher long-term care 
insurance coverage can also purchase Supplements. Supplements are plans which 
complement one’s basic CareShield Life plan by offering additional benefits, such as 
higher monthly payout amounts, which enhances the coverage. 
CareShield Life premium 
subsidies and supportTo ensure that no one will lose CareShield Life coverage due to genuine inability to 
pay, the Government provides the following premium subsidies and support:
• Means-tested premium subsidies of up to 30% of premiums of CareShield Life, 
to help lower- to middle-income households.
• Participation incentives of up to $2,500 for Singapore Citizens, if they join 
CareShield Life by 31 December 2023, to encourage those born in 1979 or 
earlier to join CareShield Life.


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• Participation incentives of up to $2,500 for Singapore Citizens, if they join 
CareShield Life by 31 December 2023, to encourage those born in 1979 or 
earlier to join CareShield Life.
• Additional participation incentives of $1,500 for Merdeka and Pioneer 
Generation citizens if they join CareShield Life by 31 December 2023.
• Additional Premium Support for Singaporeans who are unable to pay their 
CareShield Life premiums even after premium subsidies, so that no one will lose 
coverage under CareShield Life due to genuine inability to pay premiums.
Enhanced benefits under 
CareShield LifeCareShield Life features higher payouts that increase over time with no cap on 
payout duration, to provide better protection against the uncertainty of long-term 
care costs in the event of severe disability. 
• Lifetime cash payouts for as long as the policyholder is severely disabled.
• Payouts increase until age 67 or when a claim is made, whichever is earlier, with 
payouts starting at S$600 per month in 2020.
CareShield Life Premiums • The CareShield Life scheme makes use of pre-funded premiums i.e. the insured 
CPF members pay more than the cost of their health risk, while they are 
younger, to cover for the higher risk in their later years.
• For Singapore Residents born 1980 or later (future cohorts),  premiums are paid 
from the age of enrolment until age 67. Premiums will increase over time, to 
support payout increases.
• Singapore Residents born in 1979 or earlier (existing cohorts) will pay a base 
premium.
• Fully payable by MediSave.

35
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Eligibility Criteria for 
Payment of CareShield Life 
BenefitsSimilar to that of ElderShield.
Other key features of 
CareShield Life• Guaranteed renewable on an annual basis.
• Worldwide coverage.
• Minimum entry age of 30 years old, but no maximum entry age.
• CareShield Life policy will be terminated if the insured is no longer a Singapore 
Citizen or SPR.
• No cash surrender value.
Other healthcare financing 
schemes set up by the 
Singapore government• Pioneer Generation Package;
• Merdeka Generation Package;
• Interim Disability Assistance Programme For The Elderly (IDAPE);
• ElderFund and
• Medifund.
• COVID-19 Medical Bills
Interim Disability 
Assistance Programme For 
The Elderly (IDAPE)• IDAPE was launched by the Government to take care of Singaporeans who were 
not eligible to join the ElderShield scheme, when it was launched in September 
2002, either because they exceeded the maximum entry age or they had a pre-
existing disability.
Singaporean will qualify for IDAPE if:
• He is unable to perform three or more of the 6 Activities of Daily Living (ADL) - 
washing, feeding, dressing, toileting, mobility and transferring.
• He is a Singapore citizen born before 30 September 1932 OR born between 
1 October 1932 and 30 September 1962 (both dates inclusive) but with pre-
existing disabilities as at 30 September 2002.
• His per capita household monthly income is $2,800 or less OR he has no 
household income and is living in a residence with Annual Value of $13,000 and 
below.
IDAPE Payout
*An IDAPE applicant from a household with no income will qualify for the S$250 
monthly payout if the annual value of his place of residence is S$13,000 or lower.
ElderFund ElderFund is a discretionary assistance scheme launched on 31 January 2020. It is 
targeted at severely disabled lower-income Singapore Citizens aged 30 and older, 
who are not able to benefit from CareShield Life, ElderShield, and the Interim 
Disability Assistance Programme for the Elderly (IDAPE), have low MediSave 
balances and have inadequate personal savings to meet their long-term care needs.
MediFund MediFund is an endowment fund set up by the Government. It provides a safety net 
for needy Singaporeans who face difficulties paying for their remaining healthcare 
bills after Government subsidies, insurance and MediSave.Per Capita Household Income*IDAPE Payout
(With Effect From 1 July 2013)
(a) S$0 to S$2,000 (a) S$250 per month for up to 72 
months
(b) S$2,001 to S$2,800 (b) S$150 per month for up to 72 
months

10.Common Policy Provisions
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]  221  CHAPTER 10  
COMMON POLICY PROVISIONS 
CHAPTER OUTLINE  
1. Introduction
2. Sections Of A Policy Contract
3.


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4]  221  CHAPTER 10  
COMMON POLICY PROVISIONS 
CHAPTER OUTLINE  
1. Introduction
2. Sections Of A Policy Contract
3. Policy Schedule
4. Insuring Clause & Definitions
5. General Conditions
6. Benefit Provisions
7. Exclusions
8. Claim Conditions
9. Endorsements
10. Conclusion
Appendix 10A – Policy Schedule
LEARNING OUTCOMES  
After studying this chapter, you should be able to:  
▪list the sections of a Health Insurance policy contract
▪know the information contained in a Health Insurance policy schedule
▪outline what an insuring clause is
▪define the following common terms under a Health Insurance policy:
-dependant
-insured /insured person
-accident
-hospital
-any one disability
-covered charges
-day of hospital confinement
-registered medical practitioner /physician
-medically necessary service, supply or day of hospital confinement
-period of hospital confinement
-pre-existing condition
-policyholder/policy owner
-usual, customary and reasonable
-waiting period
-illness
-pre-hospitalisation benefits
-per policy year limit
-lifetime limit
-deductible and co -insurance
-pro-ration factor

Health Insurance  
222 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] ▪explain the general conditions sections that outline the rights of the policy owner and
the insurer:
-entire contract clause
-effective date of cover
-premium clauses
-free-look period
-actively at work
-termination of cover
-cover abroad
-renewal
-mis-statement of age or gender
-grace period
-reinstatement
-incontestability
-change of occupation
-co-ordination of benefits
-cancellation
-change of plan
-currency
-last payer status
-nomination of beneficiaries
-Policy Owners’ Protection Scheme
▪explain the various bases upon which Health Insurance policies can be issued:
-cancellable
-optionally renewable
-conditionally renewable
-guaranteed renewable
-non-renewable
▪understand the purposes a nd functions of the benefit provisions section of the Health
Insurance policy
▪list the common exclusions that are found in Health Insurance policies
▪explain some of the important general claim conditions commonly found in Health
Insurance policies:
-notifi cation of claim condition
-physical examination provision
-mediation/arbitration and legal action s provision
▪explain what an endorsement  is

10. Common Policy Provisions  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   223  
Contents  
CHAPTER OUTLINE  ................................ ................................ ................................ .........  221 
LEARNING OUTCOME S ................................ ................................ ................................ .. 221 
1. INTRODUCTION  ................................ ................................ ................................ ..... 225 
2. SECTIONS OF A POLICY CONTRACT  ................................ ................................ ... 225 
3. POLICY SCHEDULE  ................................ ................................ ................................  225 
4. INSURING CLAUSE & DEFINITIONS  ................................ ................................ ..... 226 
A. Insuring Clause  ................................ ................................ ................................  226 
B. Definitions  ................................ ................................ ................................ ........  226 
5. GENERAL CONDITIONS  ................................ ................................ ........................  231 
A. Entire Contract Clause ................................ ................................ .....................  231 
B. Effective Date Of Cover  ................................ ................................ ...................  231 
C. Premium Clauses  ................................ ................................ ............................  231 
D. Free-look Period  ................................ ................................ ..............................  232 
E. Actively At Work  ................................ ................................ ..............................  232 
F. Terminati on Of Cover ................................ ................................ ......................  233 
G. Cover Abroad  ................................ ................................ ................................ .. 233 
H. Renewal  ................................ ................................ ................................ ...........  234 
H1. Cancellable Policy  ................................ ................................ .....................  234 
H2. Optionally & Conditionally Renewable Policies  ................................ ...... 234 
H3. Guaranteed Renewable Policy  ................................ ................................ . 235 
H4. Non-renewable  ................................ ................................ .........................  236 
I. Mis-statement Of Age Or Gender  ................................ ................................ ... 236 
J. Grace Period  ................................ ................................ ................................ .... 236 
K. Reinstatement  ................................ ................................ ................................ .


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236 
L. Incontestability  ................................ ................................ ................................  237 
M. Change Of Occupation  ................................ ................................ ....................  237 
N. Co-ordination Of Benefits  ................................ ................................ ...............  237 
O. Cancellation  ................................ ................................ ................................ ..... 237 
P. Change Of Plan  ................................ ................................ ................................  238 
Q. Currency  ................................ ................................ ................................ ..........  238 
R.  Last Payer Status  ................................ ................................ .............................  238 
S. Nomination Of Beneficiaries  ................................ ................................ ...........  238 
T. Policy Owners’ Protection Scheme  ................................ ................................  239 
6. BENEFIT PROVISIONS  ................................ ................................ ...........................  239 
7. EXCLUSIONS  ................................ ................................ ................................ .........  241 
8. CLAIM CONDITION S ................................ ................................ ..............................  242 

Health Insurance   
 
224 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] A. Notification Of Claim Condition  ................................ ................................ ..... 242 
B. Submission Of Claim  ................................ ................................ ......................  243 
C. Physica l Examination Provision  ................................ ................................ ..... 243 
D. Mediation/Arbitration & Legal Action Provision  ................................ ............  243 
9. ENDORSEMENTS  ................................ ................................ ................................ ... 244 
10. CONCLUSION  ................................ ................................ ................................ .........  244 
Appendix 10A  ................................ ................................ ................................ ..................  245 
 
 

10. Common Policy Provisions  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   225  
1. INTRODUCTION  
 
1.1 A Health Insurance policy is the written evidence of a contract between the 
insurer and the policy owner who can be an individual or a corporation. It 
specifies the precise terms of the agreement between the two parties to the 
contract. The details of the contract terms are clearly laid out in various policy 
provisions. This chapter will describe the common and important provisions of 
Individual and Group Health Insurance contracts.  
 
1.2 It is very important to fully understand the various policy provisions to avoid 
any dispute later on.  
 
 
2. SECTIONS OF A POLICY CONTRACT  
 
2.1 There are basically seven sections in a Health Insurance policy contract.  
 
2.2 The sequence  or header  of the sections in a policy document may vary among 
the different insurers.   
 
 
3. POLICY SCHEDULE  
 
3.1 The schedule contains details of the policy  owner , insured person(s), as well as 
the insurance coverage , coverage limits and sum insured . The schedule is not 
a stand -alone document and must always be read together with the policy 
wording “ as one contract” . The schedule will also outline additional clauses or 
exclusions specific to the policy owner’s own circumstances.   
 
3.2 The schedule will include  information as follow s: 
▪ policy number;  
▪ effective date of cover;  
▪ expiry date of cover;  
▪ date at which the policy is issued;  
▪ contract currency;  
▪ name and identity number of the policy owner ; 
▪ name, age, gender and identity number of the insured  person ; 
▪ name of insurance plan;  
▪ types of riders and the coverage limits  (if any);  
▪ premium s for the insurance plan and riders;  
▪ coverage details on  benefits  limits or sum insured ; and 
▪ special  provisions/endorsements indicating the types of endorsements 
attached to the policy.  
 
 
 
 
Health Insurance 
Policy   
1. Policy Schedule  
2. Insuring Clause & 
Definitions  
3. General Conditions  
4. Benefit Provisions  
5. Exclusions  
6. Claim Conditions  
7. Endorsements  

Health Insurance   
 
226 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] 3.3 The policy schedule gives the specific details of the policy contract (refer to 
Appendix 10A of this chapter for a sample copy of the  first page of a policy 
schedule . For a detailed schedule of benefits, refer to Appendix 2A  of Chapter 
2 of this Study Guide ). When you promptly deliver the policy to the policy 
owner, you need to go through this schedule with the policy owner thoroughly , 
to ensure that there is no typographical error , and that the insurance coverage 
tallies with what the policy owner has agreed to purchase.  
 
 
4. INSURING CLAUSE & DEFINITIONS  
 
A. Insuring Clause  
 
4.1 The insuring clause also known as the operative clause states the purpose of 
the policy and outlines the conditions under which the policy will pay.


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INSURING CLAUSE & DEFINITIONS  
 
A. Insuring Clause  
 
4.1 The insuring clause also known as the operative clause states the purpose of 
the policy and outlines the conditions under which the policy will pay. The 
insuring clause serves to:  
▪ describe the general scope of coverage;  
▪ provide any definitions required;  and 
▪ set forth the cond itions under which the benefits are payable . 
 
4.2 This clause is often viewed as the foundation of a Health Insurance policy in 
terms of the insurer’s general agreement to provide the coverage.  
 
B. Definitions  
 
4.3 To ensure a common understanding for both parties , the policy contains 
definitions of key words used in  the policy.  In this section, we highlight the 
important terms in a Health Insurance policy and their sample definitions (note 
that the actual definition s vary from insurer to insurer).  
(a) Dependant  
Some Health Insurance policies provide coverage to the dependants 
(spouse and children) of the policy owner (or of the employee in the case 
of Group Insurance) and the definitions are important.  
 
A spouse is typically defined as the person to whom the policy owner is 
legally married  under the laws of the country.  
 
A spouse is no longer considered a dependant in the case of legal 
separation. As for a child, he must typically be unmarried, under the age 
of 18 years , and principally dependent on the insured for support. This 
definition also includes the legally adopted children and stepchildren of 
the insured. Most insurers will extend the cover up to age of 18 or 25  years  
if the child is pursuing a tertiary education.  
 
(b) Insured /Insured Person  
The insured person is the person covered by the insurance. The insured  
person, more often than not, is the policy owner. At times, the policy 
owner opts to cover his dependant s (spouse and children)  under the  
polic y, and in such instance, the dependants will be  the insured  persons .  

10. Common Policy Provisions  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   227  
A policy will specify that the insured person may include the policy owner , 
or any one of his insured dependants as defined in the policy.  
 
(c) Accident  
It means an incident caused by accidental, violent, external and v isible 
means.  
Note that some insurers may not have the “violent” requirement in their 
definition of “accident”.  
 
(d) Hospital  
It is defined as any lawfully operating institution which 
has 24 -hour a day nursing services by registered 
graduate nurses, one or more physicians available at all times and 
organised facilities for diagnosis and major surgery . It is not primarily a 
clinic, a place for alcoholics or drug addicts, nursing, rest or convalescent 
home , or home for the aged , or simil ar establishment.  
 
(e) Any One Disability  
It means disabilities resulting from illness or bodily injury and their 
complications arising from the same cause.  However, if any subsequent 
disability arising after a specified number of days (e.g. 45 or 90 days, 
depending on the policy wording  of the insurer ) has lapsed following the 
latest discharge from hospital, then it shall be considered a new disability , 
regardless of the cause.  
 
(f) Covered Charges  
They refer to the charges incurred by the insured person, while t he policy 
is in force, for a service, supply or period of confinement, which has been 
ordered or prescribed by a physician.   
 
A covered charge is deemed to be incurred at the time the service or 
supply is received or rendered. The covered charges for a period of 
hospital confinement are deemed to be incurred at the time of admission 
to a hospital. However, some insurers take into  account the actual date of 
provision of service.  
 
(g) Day Of Hospital Confinement  
It refers to a full 24 hours during a period of hospital confinement. The first 
day of confinement will commence at the time of admission to the hospital 
and each subsequent day  will commence 24 hours after the 
commencement of the previous day of confinement, and the day of 
discharge will also be regarded as a day of confinement.  
 
(h) Registered Medical Practitioner/Physician  
It means a qualified medical practitioner registered with the Singapore 
Medical Council to render medical and surgical services. It excludes a 
physician who is the policy owner, insured person himself or his spouse 
or any of his lineal relatives1.  
 
 
1 Lineal relatives refer to people who are descendants from the same ancestor.  
 HOSPITAL


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1 Lineal relatives refer to people who are descendants from the same ancestor.  
 HOSPITAL  
 


Health Insurance   
 
228 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] (i) Medically Necessary Service, Supply Or Day Of Hospital Confinement  
It means a service, supply or day of hospital confinement, which is 
ordered by a physician and which is:  
▪ provided for the diagnosis or direct treatment of a disability;  
▪ appropriate and consistent with the symptoms and findings or 
diagnosis and treatment of the insured person’s disability;  
▪ provided in accordance with generally accepted medical practices on 
a national basis;  
▪ the most appropriate supply or level of service which can be provided 
on a cost effective basis; and  
▪ not of an experimental or investigative nature, or research purposes.  
 
The fact that the insured person’s physician prescribes a service, supply 
or day of hospital confinement does not automatically mean that such 
service, supply or day of hospital confinement is medically neces sary.  
 
(j) Period Of Hospital Confinement   
It means a continual period of time where  an insured person is confined 
to a hospital as a registered inpatient. Two or more periods of  hospital  
confinement resulting from  the same or related causes, are considered as 
the same period of hospital confinement, unless the break between the 
date of discharge of the earlier period of hospital confinement and the 
date of admission of the following period of  hospital  confinement  is more 
than a specified number of days (e.g. 45 days) . Insurers normally require 
patients to stay in a hospital for 6 to 24 hours , before being  considered to 
be “hospitalised”.  
 
(k) Pre-existing Condition  
It is usually defined as a condition which has existed and:  
▪ for which the insured  person  received treatment or medical advice;  
▪ in respect of which the insured  person  showed symptoms;  
▪ of which the insured  person was aware;  and 
▪ of which the insured  person  should reasonably have been aware;  
 
before the date of policy issue or the date that the cover was reinstated.  
 
Note that insurers may adopt one or more of the above -mentioned  
conditions in their definition of the term “pre -existing condition”.   
 
Almost all insurers require the insured  person  to declare any known pre -
existing condition. These  pre-existing condition s may be excluded from 
coverage , and the policy  being  put in  force with the required exclusions. 
In recent years , some insurers use a moratorium underwriting  method . 
This means  that the  insured  person  does not need to make any medical 
declaration  when he applies for coverage . Pre-existing conditions can be 
covered after a continuous period (e.g. five years) from the effective date 
of coverage,  reinstatement, or upgrade of plan, whichever is the later. For 
the specified number of years, the insured  person  must not have 
experienced any symptom, seek consultati on, or receive treatment or 
medication for the condition.


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10. Common Policy Provisions  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   229  
In addition , the insurer may also have a list of pre -existing conditions that 
are permanently excluded from coverage , e.g. cancer, stroke, heart attack, 
kidney failure , etc. 
 
(l) Policyholder/ Policy Owner  
The policy owner owns the policy and is responsible for the payment of 
premiums and receipt of claims and benefits under the policy.  He has the 
right to make changes to the contract and receive all payments due under 
the policy.  
 
(m) Usual, Customary & Reasonable  
It means the charges for a specific service, supply or period of hospital 
confinement:  
▪ is within standard charge for the specific provider; and  
▪ must not be more than the general level of charges of other medical 
care providers with similar standing in the same geographical area, for 
an equivalent treatment, services or supplies to individuals of the same 
gender, of comparable age, for a similar illness or injury.  
 
(n) Waiting Period   
For Medical Expense Insurance , it refe rs to the period of time  starting from 
the date of policy issue  or reinstatement date , where  the insured  person 's 
medical expenses are not covered by the policy. Waiting period  differs 
from insurer to insurer and appl ies only to medical expenses arising from  
an illness , not from an accident.  
 
For Disability Income Insurance , it refers to a specified period of time , 
beginning with the onset of the disability, where  benefits are not payable. 
The waiting period in a Disabili ty Income Insurance policy is sometimes 
called the “elimination period” or the “probationary period”.  
 
For Long -Term Care (LTC) Insurance , it refers to a period  of time beginning 
from the first day the insured person is unable to perform the specified 
Activities of Daily Living (ADLs) , during which no LTC Insurance benefit 
will be payable.  For LTC Insurance, this may also be known as the deferred 
period.  
 
(o) Illness  
Illness refers to a physical condition marked by a pathological deviation 
from the normal healthy state.  
 
(p) Pre-hospitalisation Benefits  
This refers to the diagnostic X -ray, laboratory tests and specialist 
consultation for an illness or injury which occurred within a specified 
number of days prior to hospitalisation. The insurer will pay only for such 
outpatient treatments  if they lead to hospitalisation or surgical operation , 
within the time  frame  as specified in the policy.  
 
  


Health Insurance   
 
230 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] (q) Per Policy Year Limit  
This is the maximum amount that a Medical Expense Insurance (MEI) 
policy will pay for all the eligible medical expenses that an insured person 
incurs within each policy year.  
 
(r) Lifetime Limit  
This is the maximum amount that a MEI policy will pay for all the  eligible 
medical expenses that an insured person incurs under the policy.  
 
(s) Deductible & Co-insurance  
A deductible  is a flat amount of covered medical expenses that an insured 
person must first incur , before  the insurer will make any benefit payment 
under a MEI policy. This amount will have to be borne by the insured  
person . 
Co-insurance , on the other hand, is a percentage of all eligible medical 
expenses, in excess of the deductible, that the insured person must 
personally pay under a MEI policy.  
 
(t) Pro-ration Factor  
This is the percentage that the insurer will use to pro -rate the hospital bills 
before it compute s the claim payout , if the insured person is admitted to 
a ward/hospital higher than what he is entitled to under the policy. The 
percentage is applied on the actual charges incurred and covered under 
the policy, including charges of pre-hospital and post-hospital treatment s 
received in connection wi th the hospitalisation. Therefore, t he benefit 
payable is reduced to take into account the difference in Government 
subsidies applicable to the ward type of the selected plan.  
 
If the life assured receives inpatient treatment in a luxury or deluxe suite 
or any other special room of a hospital, the room charge benefit will be 
pro-rated to the actual charges which the life assured has to pay for each 
type of plan.  
 
Here is an example of how an insurer would  pro-rate the room charges.


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Here is an example of how an insurer would  pro-rate the room charges.  
 
Insured’s Plan 
Entitlem ent Pro-ration formulae  
Private 
Hospital – any  
standard ward   
𝐶ℎ𝑎𝑟𝑔𝑒  𝑓𝑜𝑟  𝑎 𝑠𝑖𝑛𝑔𝑙𝑒 −𝑏𝑒𝑑𝑑𝑒𝑑  𝐴1 𝑤𝑎𝑟𝑑  𝑖𝑛 𝑀𝑜𝑢𝑛𝑡  𝐸𝑙𝑖𝑧𝑎𝑏𝑒𝑡 ℎ 𝑂𝑟𝑐 ℎ𝑎𝑟𝑑  𝐻𝑜𝑠𝑝𝑖𝑡𝑎𝑙
𝑅𝑜𝑜𝑚  𝑐ℎ𝑎𝑟𝑔𝑒  𝑤ℎ𝑖𝑐ℎ 𝑡ℎ𝑒 𝒍𝒊𝒇𝒆  𝒂𝒔𝒔𝒖𝒓𝒆𝒅  ℎ𝑎𝑑 𝑡𝑜 𝑝𝑎𝑦    
 
x total bill  
 
Restructured 
Hospital – any  
stand ard ward   
𝐶ℎ𝑎𝑟𝑔𝑒  𝑓𝑜𝑟  𝑎 𝑠𝑡𝑎𝑛𝑑𝑎𝑟𝑑  𝐴1 𝑤𝑎𝑟𝑑  𝑖𝑛 𝑆𝑖𝑛𝑔𝑎𝑝𝑜𝑟𝑒  𝐺𝑒𝑛𝑒𝑟𝑎𝑙  𝐻𝑜𝑠𝑝𝑖𝑡𝑎𝑙
𝑅𝑜𝑜𝑚  𝑐ℎ𝑎𝑟𝑔𝑒  𝑤ℎ𝑖𝑐ℎ 𝑡ℎ𝑒 𝒍𝒊𝒇𝒆  𝒂𝒔𝒔𝒖𝒓𝒆𝒅  ℎ𝑎𝑑 𝑡𝑜 𝑝𝑎𝑦  x total bill  
 
Restructured 
Hospital – any  
standard B1 
Ward   
𝐶ℎ𝑎𝑟𝑔𝑒  𝑓𝑜𝑟  𝑎 𝑠𝑡𝑎𝑛𝑑𝑎𝑟𝑑  𝐵1 𝑤𝑎𝑟𝑑  𝑖𝑛 𝑆𝑖𝑛𝑔𝑎𝑝𝑜𝑟𝑒  𝐺𝑒𝑛𝑒𝑟𝑎𝑙  𝐻𝑜𝑠𝑝𝑖𝑡𝑎𝑙
𝑅𝑜𝑜𝑚  𝑐ℎ𝑎𝑟𝑔𝑒  𝑤ℎ𝑖𝑐ℎ 𝑡ℎ𝑒 𝒍𝒊𝒇𝒆  𝒂𝒔𝒔𝒖𝒓𝒆𝒅  ℎ𝑎𝑑 𝑡𝑜 𝑝𝑎𝑦  x total bill  
 

10. Common Policy Provisions  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   231  
5. GENERAL CONDITIONS  
 
5.1 The general conditions section outlines the rights of both the policy owner and 
the insurer. In this section, we highlight some of the important conditions as 
found in a typical Health Insurance policy.  
 
A. Entire Contract Clause  
 
5.2 All insurance contracts have an “Entire Contract Clause”. In some policies, it is 
referred to as “The Policy Contract Clause”.


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A. Entire Contract Clause  
 
5.2 All insurance contracts have an “Entire Contract Clause”. In some policies, it is 
referred to as “The Policy Contract Clause”. This clause states that the present 
contract, together with any specified attachments/endorsements, make up the 
entire contract , and no other documents f orm another part of the contract. In a 
Health Insurance contract, the policy document and the proposal form  (as well 
as proposal forms  of the insured  persons , if required in the case of a family or 
group polic y) are the entire contract between the insured and the insurer.  
 
5.3 This clause also states that , in consideration of the first premium being received 
in full, the insurer will start providing benefits as set out in the policy.   
 
B. Effective Date Of Cover  
 
5.4 The effective date of cover is established in the policy by agreement between 
the insurer and the  policy owner . It is the date on which the insured person 
begins to be covered under the Health Insurance policy.   
 
5.5 Usually, the effective date of cover applies to all types of cover s under  the 
policy , unless there is a special arrangement to have one or more of the covers 
to become effective at some later date.  
 
5.6 For instance, the effective date of cover for an accident  or illne ss may be  
different. For an accident , cover will commence as at the effective date of the  
insurance. For  an illness , the cover can commence  only after the waiting period  
is over.     
 
C. Premium Clauses  
 
5.7 Health Insurance policies are issued by life insurers. Policies such as medical 
expense insurance can also be issued by general insurers.  
 
5.8 As far as individual Health Insurance policies issued by life insurers are 
concerned, when the policy is first incepted, the premiums must be paid before 
inceptio n of cover. When the policy is renewed during the second year onwards, 
it is subject to a Grace Period whereby the premium must be paid within 30 
days from inception of cover.  
 
5.9 For Group Health insurance policies issued by life insurers, there is a Grace 
Period  provision within such policies which states that the premium has to be 
paid within 30 days from the commencement date or renewal date (whichever 
is applicable); or the date of the insurer’s premium tax invoice, whichever is 
later . 
 
 


Health Insurance   
 
232 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] 5.10 We now turn to Hea lth Insurance policies issued by general insurers. For 
individual health insurance policies issued by general insurers, they are subject 
to the Payment Before Cover Warranty  which states that the policy shall not be 
in force, unless the premium is paid to the insurer or intermediary on or before 
the date of inception of the policy. In the event that the total premium due is not 
paid to the insurer or the intermediary on or before the inception date or the 
renewal date of the policy or Bond, then no benefits  whatsoever shall be 
payable by the insurer.  
 
5.11 As for Group Health insurance policies (e.g. Group Medical Insurance or Group 
Hospital and Surgical Insurance) issued by general insurers, they are subject to 
the Premium Payment Warranty  which states that if t he period of insurance is 
more than 60 days, the policyholder is required to pay the premium due under 
the policy in full, within 60 days from the date of inception of the policy. If this 
warranty is not complied with, then the policy is automatically term inated from 
the expiry of the 60 -day period, and the insurer will be entitled to a pro -rata 
premium for the 60 -day period that the insurer has been on risk. If the period of 
insurance is less than 60 days, then the insured is required to pay the premium 
due under the policy in full, within the period of insurance.  
 
D. Free-look Period  
 
5.12 The free -look period is the period of time after delivery of the policy document 
during which the policy owner may review the policy and return it for a refund 
of the premium paid to the insurer  (less any medical fees incurred). Full 
coverage is in force during this period. This can vary from 14 to 30 days from 
the date of receipt of the policy document. The policy  document is deemed to 
have been received by the policy owner within seven days after the insurer has 
despatched it.  
 
E. Actively At Work  
 
5.13 This provision is usually found in Group Insurance , as well as Disability Income 
Insurance.


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E. Actively At Work  
 
5.13 This provision is usually found in Group Insurance , as well as Disability Income 
Insurance. When applied to Group Ins urance, it provides that an employee is 
not eligible for coverage , if he is absent from work because of an illness , injury 
and other reasons on the effective date of his coverage. However, in Disability 
Income Insurance, it provides that the cover will aut omatically terminate , when 
the person is not working owing to illness or termination of service.  
 
  

10. Common Policy Provisions  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   233  
F. Termination Of Cover  
 
5.14 This clause lists the situations , whereby the cover for Health Insurance will 
cease:  
▪ when the insured  person  dies;  
▪ when the policy owner fails to pay the renewal premium at the end of the 
grace period;  
▪ when the total amount of claims paid by the insurer has reached the limit of 
indemnity ; or 
▪ when the insured  person  reaches the specified maximum age during  which 
the insurer is not willing to offer cover.  
 
5.15 It also states that the termination of a policy will not prejudice or affect the 
payment of any claim that has arisen before the termination , and that there will 
be no refund of premium if the policy is terminated before the expiry of the 
cover.  
 
G. Cover Abroad  
 
5.16 This clause is applicable only to the covered charges incurred in the “Country” 
as specified in the policy schedule. It is also applicable under the following 
circumstances:  
▪ the insured  person , travelling abroad for a reason other than for medical 
treatmen t, needs to be confined to a hospital outside the “Country” as a 
consequence of a medical emergency occurring within 90 days of leaving the 
“Country”; or  
▪ the insured  person , upon recommendation of a physician and with the prior 
written approval of the chief medical officer of the insurer, has to be 
transferred to a hospital outside the “Country” because the specialised 
nature of the treatment, aid, information or decision required can neither be 
rendered, nor furnished, nor taken, in  that “Country”.  
 
5.17 All co vered charges incurred during the period of confinement will be subject 
to the exclusions, limitations and conditions as specified in the policy , and all 
benefits will be payable in the “Currency”2 based on  the “Exchange Rate”3 on 
the last day of the period of confinement.  
 
5.18 The purpose of this clause is to restrict the Health Insurance coverage to the 
country where the policy is issued; except when the insured person is travelling 
abroad and, at the time of an emergency, the cha rges for an overseas hospital 
treatment will be covered. As the cost of healthcare varies from country to 
country, pricing of the product does not usually take into account any foreign 
country’s claim costs. Furthermore , it complicates claim administration  and 
adjudication.  
 
 
2  “Currency” refers to any currency other than Singapore dollars.  
3  “Exchange Rate” refers to the rate of exchange used for the settlement of a claim.   


Health Insurance   
 
234 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] H. Renewal  
 
5.19 The Renewal Provision describes:  
▪ the circumstances under which the insurer has the right to refuse to renew 
or the right to cancel the coverage; and  
▪ the insurer’s right to increase the amount of premium payable on the polic y. 
 
5.20 Health Insurance policies can be issued on any of the following bases:  
▪ cancellable;  
▪ optionally renewable;  
▪ conditionally renewable;  
▪ guaranteed renewable ; or 
▪ non-renewable.   
 
5.21 Let us look at each of the five types of Health Insurance policies in turn.  
 
H1. Cancellable Policy  
 
5.22 The Renewal Provision included in a cancellable policy (e.g. some Medical 
Expense Insurance policies) grants the insurer the right to terminate the policy 
at any time, for any reason, si mply by notifying the policy owner in writing that 
the policy is cancelled , and by refunding any advance premium that has been 
paid for the policy.   
 
5.23 All things being equal, cancellable policies are generally cheaper than other 
types of policies.  
 
H2.


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5.23 All things being equal, cancellable policies are generally cheaper than other 
types of policies.  
 
H2. Optionally & Conditionally Renewable Policies  
 
5.24 To remain in force, Health Insurance policies must be renewed periodically; that 
is, the coverage remains in force only for the length of time for which the 
premiums have been paid.  When the premium is due again, the policy may be 
renewed , or it may expire . Both the policy owner and the insurer have a role to 
play in the renewal process.  
 
5.25 The policy owner has the option to cancel the policy at any time by notifying 
the insurer  within a specified period during the currency of the policy , or by  
allowing it to lapse at a premium due date by not paying the premium.  
 
5.26 Health Insurance policies also include specific provisions that will determine 
whether the insurer may refuse to rene w a policy.  When the insurer has the 
option to refuse to renew, the policy may be one of two types:  
▪ Optionally Renewable Policy  
The insurer has the right to refuse to renew an optionally renewable policy 
on certain dates as specified in the policy , usually either on the policy 
anniversary date or on any premium due date.  The insurer is also allowed to 
increase its premium rate and to add coverage limitations, such as 
eliminating coverage for injuries to certain parts of the body, or limiting the 

10. Common Policy Provisions  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   235  
extent of coverage for certain occurrences.  
▪ Conditionally  Renewable Policy  
The insurer may elect not to renew only under conditions  as specified in the 
policy. These conditions cannot be related to the insured  person ’s health.  
Provided that the insurer is still selling this line of business, the age and 
employment status of the insured  person  are often listed as reasons for 
possible non -rene wal. For example, an individual Disability Income 
Insurance policy may state that the insurer will renew the policy until the 
insured  person  reaches a certain age  (e.g. 65 years) , or until the insured  
person  retires from gainful employment. A conditionally renewable policy 
also gives the insurer the right to increase the premium rate.  
To protect the insured  person  when a valid claim is being paid or is eligible 
for payment at the time when the premium is due , the insurer may not 
prejudice that claim. That is, the claim will be paid if the insurer elects not to 
renew the policy.  
 
H3. Guaranteed Renewable Policy  
 
5.27 In some  policies, the insurer relinquishes the rights to cancel the policy at any 
time, as well as  to refuse renewal at a premium due date. This type of policy is 
said to be guaranteed renewable , and it includes several important features , 
such as : 
▪ renewal is guaranteed , as long as the policy owner pays the premium;  
▪ the insurer may not cancel the policy , unless the policy owner fails to pay the 
premium;  
▪ premiums may be increased on the basis of an entire classification, such as 
occupation or sub -plan;  and 
▪ guarantee d policy renewal until the specified age, such as 60 , 65, 70 or 75 
years , depending o n the insurer’s policy . 
 
5.28 Non-payment of premium is the only r eason that an insurer may cancel or 
refuse to renew a guaranteed renewable policy.   
 
5.29 However, it may increase the premiums based on a class  basis. One common 
classification, for example, is by o ccupational groups. Based on experience, the 
insurer know s that certain occupations are subject to a higher risk of accidental 
injury or death than other occupations. For example, compare the different risks 
faced by a n office administrator and by a construction worker.   
 
5.30 With a guaranteed renewable policy, the insurer must  renew the policy when it 
is due. However, based on new experience ratings within the insured  person ’s 
occupational class, the insurer may increase th e premiums for all insured  
persons  in that class of risk.  
 
5.31 The guaranteed renewable feature is often limited . In some policies, the insurer 
regains the right to cancel and to refuse to renew , when the insured  person  
reaches a specified age.  Commonly, the p olicy will stipulate this right , when the 
insured  person  reaches a normally accepted retirement age, such as 60, 65 , 70 
or 75 years .


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Commonly, the p olicy will stipulate this right , when the 
insured  person  reaches a normally accepted retirement age, such as 60, 65 , 70 
or 75 years .   


Health Insurance   
 
236 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] 5.32 Since insurers expose themselves to higher risks by relinquishing the rights to 
refuse renewal and to cancel such polic ies, premiums for guaranteed renewable 
polic ies are generally higher than those for cancellable policies.  
 
H4. Non-renewable  
 
5.33 In some situations, an individual may need Health Insurance for a fixed, limited 
period of time. Coverage that extends only for a specified length of time is called 
Term Insurance. Such a policy cannot be renewed at all. When it expires, the 
insured person  must purchase another policy.  
5.34 Travel Insurance is a  typical  example of a form of Term Insurance. It essentially 
covers from the start to the end of the trip . Student Personal Accident  Insurance  
policy is another example, beginning when the school term starts and ending 
when the school term is over.  
 
I. Mis-stateme nt Of Age Or Gender  
 
5.35 The provision specifies that , in the case of an insured person mis-stating his 
age or gender, the insurer will adjust the premium based on his correct age and 
gender. Any excess premium paid will be refunded  by the insurer , and any 
shortfall in premium will have to be made up by the policy owner . However, if 
at the correct age, an insured person would not have been eligible for coverage 
under the policy, then no benefit would be payable  by the insurer . 
 
J. Grace Period  
 
5.36 Individual Health Insurance policies contain a Grace Period provision  that 
allows the policy owner to pay a renewal premium , within a stated grace period , 
following the premium due date. The length of the grace period may vary 
depending on how frequently the renewal premium is payable. The grace 
period is usually 30 days for most policies.  Coverage remains in force during 
the grace period.  
 
K. Reinstatement  
 
5.37 An i ndividual Health Insurance polic y typically include s a Reinstatement 
provision  stating that , if certain conditions are met, the insurer will reinstate a 
policy that has lapsed for non -payment of premiums. The policy owner must 
pay any overdue premium  (with or without interest as determined by the 
insurer)  and the insured person must complete a reinstatement 
application /health warranty . The insurer has the right to evaluate the 
reinstatement application , and to decline to reinstate the policy on the basis of 
statements made in that application. Coverage under a reinstated policy can be 
limited to  any accident or illness that will occur only after the effective date of 
reinstatement.  
 
5.38 Thus, the insurer ca n protect against anti -selection by excluding from cover, 
those losses that occur  only after the lapse of the policy and before it is being 
reinstated.  
   
 
 
 


10. Common Policy Provisions  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   237  
L. Incontestability  
 
5.39 Health Insurance riders attached to Life Insurance policies will be subject to the  
Incontestability Clause. The Incontestability provision makes Life Insurance 
policies indisputable after they have been in force for a certain minimum  period 
(usually one year) , with the exception of fraud.  In other words, this provision 
stops the insurer  from repudiating liability under a policy purely on grounds of 
breach of utmost good faith , except when fraud has been proven.  
 
M. Change Of Occupation  
  
5.40 Many individual Disability Income Insurance policies contain a Change Of 
Occupation provision  that pe rmits the insurer to adjust the premium rate or the 
amount of benefits payable under the policy if the insured  person  changes 
occupation. The insured  person ’s occupation has a direct effect on his morbidity 
risk. The Change Of Occupation provision typicall y permits the insurer to reduce 
the maximum benefit amount payable under the policy should the insured 
person change to a more hazardous occupation. Should the insured  person  
change to a less hazardous occupation, th is provision would also permit the 
insurer to reduce the premium rate  of the policy.  
 
N. Co-ordination Of Benefits  
 
5.41 Many individual Health Insurance policies contain a Co -ordination of Benefits  
provision  (may also be known as Over -insurance provision  or Contribution 
provision ) that is intended to prevent the insured person from profiting from a 
claim .


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This provision states that the benefits payable under the policy will be 
reduced if the insured  person  is eligible for reimbursement from other sources.   
 
5.42 Co-ordination of Benefits provision will apply whether or not the insurer has 
been notified of the other coverage at the application  stage . Should there be 
over -insurance, the insurer would reduce the amou nt of benefits that would 
otherwise be payable under the policy. In case s, whereby the insurer realises 
that the insured  person  has also received benefits from other sources only after 
it has paid out the benefits, the insurer may, at its discretion, demand a return 
of all or part of the benefits previously paid  under the policy .  
 
O. Cancellation  
 
5.43 A Health Insurance policy may have a provision that allows the policy owner to 
cancel the policy by giving written notice to the insurer  within a certain period 
of time (e.g. seven days) . In such  a case , the policy owner is usually entitled to 
a return of the excess premium paid less an y administrative cost as determined 
by the insurer. The policy owner must also state  when  such cancellation shall  
become effective , usually not less than 30 days thereafter . 
 
5.44 After such return of premium, the insurer will not be liable for any benefits in 
respect of covered charges incurred during the policy year in which the 
cancellation becomes effective.  
 
 

Health Insurance   
 
238 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] 5.45 This pr ovision often goes hand -in-hand with the renewal provision of a 
cancellable policy , such that the insurer also has the right to terminate the policy 
at any time, simply by notifying the policy owner in writing , and by refunding 
any advance premium that has  been paid for the policy. This applies  not only  
to an Individual Health Insurance polic y, but also  to a Group Health Insurance 
policy (where the policy owner is usually the employer).  
 
P. Change Of Plan  
 
5.46 A Medical Expense Insurance policy has a provision to allow the insured  person  
to upgrade or downgrade  the coverage plan. Any upgrading of plan is  subject 
to satisfactory evidence of insurability at the policy owner’s expense . He may 
request for a change of plan either at the next policy renewal date or the next 
premium due date.  An a pplication for change of plan should be submitted by 
the insured  person  to the insurer at least 30 days , before the policy renewal date 
or premium due date . However, the insurer may refuse to accept such an 
application.  
 
5.47 Any medical condition that is covered under the plan  immediately before the 
plan change  will continue to be covered , and claims on such condition will be 
payable  according to the limits of the plan before  its change.  
 
Q. Currency  
 
5.48 Where payment of claims is on reimbursement bas is, the policy will state the 
currency for the benefits payable. Generally, payment of all claims and benefits 
will be made in Singapore currency. Charges incurred in any other currency 
outside Singapore shall be payable in Singapore currency on the basis of the 
exchange rate used by the insurer on  the date of processing the claims.  
 
R.  Last Payer Status  
 
5.49 This clause  appears  in the MediShield Life and Private Integrated Shield Plans. 
It states that , if the insured  person  has any other Medical Insurance, including 
medical benefits (such as from Work Injury Compensation Insurance) under any 
employment contract, which makes provision for reimbursement of medical 
expenses, the insurer shall be the last payer reimbursing the claim. If benefits 
payabl e under the policy have  been made to the insured person first, before a 
claim is made under such other Medical Insurance policies or employee 
benefits, the other medical insurers or the employer will need to reimburse the 
existing insurer its share. The insured  person  shall provide the insurer with the 
full details of such other insurance policies or employee benefits , and all 
relevant documentary proof necessary to make a claim.  
 
S. Nomination Of Beneficiaries  
 
5.50 The introduction  of the Nomination Of Benef iciaries (NOB) under Part 3C of the 
Insurance Act 1966  as from 1 September 2009 gives policyowners of Life 
Insurance policies or A&H Insurance policies with death benefits, a clear and 
affordable legal means to distribute the policy benefits to their nomin ees. 
 

10. Common Policy Provisions  
Copyright reserved by the Singapore College of Insurance Limited [Version 1.


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10. Common Policy Provisions  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   239  
5.51 Since CI Insurance policies usually have built -in death benefits payable, they 
will come under the NOB framework. Hence, the insured who is the policyowner 
can make a nomination as long as he has attained the age of 18 years. Two 
options of nominatio n as briefly described below are available:  
▪ Trust or Irrevocable Nomination ( Section 132 of the Act ) – The insured loses 
all rights to the ownership of the policy. To revoke this trust nomination, 
the insured needs the written consent of all the nominees.  
▪ Revocable Nomination ( Section 133 of the Act ) – The insured retains the 
ownership of the policy and is free to change, add or remove nominees, 
without their consent.  
 
T. Policy Owners’ Protection Scheme  
 
5.52 Singapore  consumers enjoy the benefits of a sound fi nancial system. Insurers 
licensed in Singapore are supervised by the Monetary Authority of Singapore 
(MAS) whose aim is to ensure the stability of the financial system in Singapore , 
and to require financial institutions to have sound risk management systems 
and adequate internal controls. However, MAS does not guarantee the 
soundness of individual financial institutions. Therefore, the Policy Owners’ 
Protection Scheme (PPF Scheme) ha s been set up  to protect the policy owners 
in the event of failure of a life or general insurer which is a PPF Scheme member.  
 
5.53 The scope of PPF Scheme includes (but not limited to) individual and group 
short -term or long -term accident and health (A&H) policies (e.g. Hospital  
Income , Medical Expense, Personal Accident, Disability Income, Long -Term 
Care  Insurance ).  
 
5.54 The PPF Scheme is administered by the Singapore Deposit Insurance 
Corporation (SDIC). Coverage under the PPF Scheme is automatic , and no 
further action is required from  the policy owner s. For more information on the 
types of benefits that are covered under the scheme , as well as the limits of 
coverage, where applicable, just refer to the SDIC Website at : www.sdic.org.sg   
 
 
6. BENEFIT PROVISIONS  
 
6.1 The benefit provisions section is the essence of any insurance  policy. The 
benefit provisions set forth the insurer’s promises. Each benefit provided by the 
insurance policy is explained in detail, indicating what will be paid, the 
conditions that establish the insurer’s liability to make payment, the conditions 
under which p ayment will be made, the nature and extent of benefits payable, 
and the applicable benefit limitations.  
 
6.2 Benefit provisions are written with utmost care. They must be clear and precise, 
but at the same time broad enough to cover virtually any claim situati on that 
can conceivably arise.  
 
6.3 Let us take a look at some of the benefit provisions of a Medical Expense 
Insurance policy as an example.  
  

Health Insurance   
 
240 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]  
BENEFIT PROVISIONS  
 
A. Hospital And Surgical Benefits  
 
“The Company agrees that if any disease, illness or injury necessitates the 
Insured  Person  to be confined to a Hospital as an Inpatient or for day surgery 
while he  or she is covered under this Policy, the Company will pay the 
appropriate benefit stated below, su bject to the limits set out in the Schedule 
of Benefits. Provided that the Insured  Person  has actually incurred the 
charges , the Company shall pay an amount equivalent to the actual charges 
incurred or the reasonable and customary charges or the maximum su m as 
specified in the Policy Schedule in respect of the incident concerned, 
whichever is the lowest.  
 
1. Daily Hospital Room and Board  
Charges for room accommodation, meals  and general nursing services 
for the insured  person . 
 
2. Intensive Care Unit  
Charges incurred during confinement as an Inpatient in the Intensive Care 
Unit of the Hospital.  
 
3. Hospital Miscellaneous Expenses  
(a) Prescription of Drugs  
Charges for drugs prescribed which are medically necessary and 
directly in connection with the I nsured  Person ’s disability , provided 
that such drugs are listed in the Singapore Index Medical Supplies 
(SIMS) and excluding charges for drugs prescribed for us e beyond 
sixty (60) days after discharge from the Hospital.


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(b)  Inpatient Diagnostic Procedures and Inpatient Physiotherapy  
Charges for Inpatient Diagnostic Procedures or Inpatient Physiotherapy 
that relates directly to the Disability and is medically ne cessary for 
which the Insured Person receives treatment as an inpatient.  
 
(c) Ambulance Charges  
Charges incurred for necessary domestic ambulance service (inclusive 
of attendance) to and/or from the Hospital , provided that the Insured  
Person  is admitted as an Inpatient.  
 
 
 
6.4 Note: “The Company” means the insurance company named in the policy 
schedule.  
 
 
 
 
 

10. Common Policy Provisions  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   241  
7. EXCLUSIONS  
 
7.1 Exclusions refer to the circumstances under which the insurer will not pay. In 
this section, we will highlight some important exclusions commonly found in a 
typical Health Insurance policy.  
 
7.2 No benefits will be paid for charges which are in excess of the usual, customary 
and reasonable charges . Illness contracted within the waiting period, pre -
existing conditions and the following  categories will also not be covered  by the 
policy : 
 
(a) Surgical Procedures Or Examinations  
(i) routine physical, pre -emplo yment or premarital examination, 
immunisation or circumcision ; 
(ii) refraction, eye glasses or contact lenses , including fittings and 
examinations, or surgical correction of near -sightedness (such as, 
but not limited to, radial keratotomy and keratectomy);  
(iii) exam ination, treatment or surgery of the teeth, gums or direct 
supporting structure, except as necessitated by an injury to sound 
natural teeth occurring while the cover for the insured person under 
this contract is in force;  
(iv) aesthetic or cosmetic surgery, exc ept for charges for treatment 
resulting from  an injury which occurs while the cover for the insured 
person under the contract is in force. Such treatment must take place 
within 12 months of the injury , and while the cover for the insured 
person under this contract is in force;  
(v) pregnancy, childbirth (including surgical delivery), abortion or 
miscarriage (except as a result of an injury) and pre -natal or post -
natal care;  
(vi) prosthesis, corrective devices or medical appliances which are not 
medically necessary;  
(vii) donation of any body organ by the insured  person ; and 
(viii) gender changes . 
 
(b) Treatments  
(i) test or treatment related to impotence, infertility, contraception or 
sterilisation;  
(ii) treatment owing  to birth defect, hereditary or congenital condition;  
(iii) treatment of any diagnosed emotional, mental or nervous disability , 
including any condition caused by or resulting from such disability;  
(iv) treatment which is in any way related to sexually transmitted 
disease, Acquired Immun e Deficiency Syndrome (AIDS) , or any 
infection from a human immunodeficiency virus (HIV) , as well as 
their related complications ; 
(v) treatment resulting from suicide, attempted suicide,  self-inflicted 
injury, narcotic or alcohol abuse, or participation in hazardous 
pursuit;  
(vi) treatment of a disability that results from participation in any assault, 
criminal or unlawful act, strike, civil disorder or riot;  
(vii) treatment directly or indirectly associated with invasion, act of 
foreign enem y, hostili ty or any act of war, whether or not declared, 

Health Insurance   
 
242 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] civil war , rebellion, revolution, insurrection or military or usurped 
power , or full -time service in any of the armed forces , except for 
peacetime reservist training or mobilisation exercise in accordance 
with the Enlistment Act 1970 ; 
(viii) treatment of a disability resulting from the use of nuclear weapon or 
from contact with nuclear material;  
(ix) treatment of morbid obesity or related conditions;  and 
(x) treatment arising from the insured  person ’s failure to act on proper 
medical advice . 
 
(c) Confinement  
(i) services, supplies or confinement days , which are not medically 
necessary;  
(ii) period of confinement resulting from  a disability not requiring 
surgery , unless the period of confinement is more than a specified 
period of time (e.g.12 or 18 hours ); and 
(iii) convalescent care, rest care, hospice care, rehabilitation or similar 
treatment.


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(d) Other  Services  
(i) service performed by a person who ordinarily resides in the  insured 
person’s home or is a close relative;  
(ii) transportation, other than ambulance transfer in the event of a 
medical emergency;  and 
(iii) ancillary expenses , such as (but not limited to ) television, telephone, 
video, newspaper and family accommodation  charges . 
 
7.3 The list of exclusions changes from time to time , as new technologies surface 
which in turn affect medical cost.  
 
 
8. CLAIM CONDITIONS  
 
8.1 In this section, we highlight some important general claim conditions 
commonly found in a Health Insurance policy.  
 
A. Notification Of Claim Condition  
 
8.2 A typical Health Insurance polic y include s provisions that define the insured’s 
obligation to provide t imely notification of loss to the insurer . 
 
8.3 The period of time given to the policy owner to notify the insurer varies from 
policy to policy. For instance, instead of the usual 30 days, a Medical Expense 
Insurance policy may require the insured to notify the insurer , within 14 or 21 
days from the date of hospital confinement.  
 
  
CLAIM  

10. Common Policy Provisions  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   243  
B. Submission Of Claim  
 
8.4 The policy owner must (at his own expense) give the insurer all certificates , 
forms, bills , receipts , information and evidence as required by the insurer . The 
policy owner must submit only original bills, invoices, receipts , discharge 
summary  and other documents required to support a claim  lodged with the 
insurer , unless such evidence and documents are electronically submitted on 
behalf of the insur ed person  by a hospital or medical clinic or other medical 
establishment through the electronic submission system , MediClaim.   
 
C. Physical Examination Provision  
 
8.5 The Physical Examination provision included in most individual and group 
Disability Income policies is similar. After the policy owner  submits a claim, the 
insurer has the right to have the insured person examined by  a doctor of the 
insurer’s choice, at the insurer’s expense. Therefore, t he insurer  has the 
opportunity to verify the validity of any Disability Income claim  submitted by 
the insured or claimant .  
      
D. Mediation/Arbitration & Legal Action Provision  
 
8.6 An individual Health Insurance policy will usually include a Dispute Resolution 
Clause. It specifies that any dispute or matter arising under the policy should be 
referred to the Financial Industry Disputes Resolution Centre Ltd (FIDReC) to be 
dealt with accordingly.  The policy owner should refer such dispute or matter to 
FIDReC within six months from the date of failure to reach an agreement with 
the insurer.  
 
8.7 If the dispute cannot be referred to or dealt with by FIDReC, the dispute will be 
referred to and decided using arbitration . This will be according to the 
Arbitration Rules of the Singapore International Arbitration Centre applicable  at 
that point of time. The policy also states that the insurer will not be legally 
responsible under the policy, unless the policy owner has first received an 
award under arbitration.  
 
8.8 Where both mediation and arbitration fail to settle the dispute, the policy owner 
may seek legal action against the insurer. The Legal Action Provision limits the 
time during which the policy owner who disagrees with the insurer’s claim 
decision has the right to sue the insurer , to collect the amount which he believes 
is owe d under the policy. The policy may state that no action in law or equity 
will be brought under the policy until after the expiration of 60 days from the 
date a satisfactory proof of claim has been furnished to the insurance company 
in accord ance with  the t erms and conditions of the policy.  
 
8.9 A policy issued by an insurer in Singapore will be construed according to and 
governed by the laws of the Republic of Singapore. These laws will apply in the 
event of any conflict or dispute under the policy, and the parties to the conflict 
or dispute must agree to submit themselves to the exclusiv e venue and 
jurisdiction of the Courts of the Republic of Singapore for the resolution of any 
conflict or dispute.  
 
 

Health Insurance   
 
244 Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4] 9. ENDORSEMENTS  
 
9.1 An endorsement is a separate document that modifies the policy to which it is 
attached. There are several types of endorsements concerning the policy 
wording, benefits or exclusions, etc.


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ENDORSEMENTS  
 
9.1 An endorsement is a separate document that modifies the policy to which it is 
attached. There are several types of endorsements concerning the policy 
wording, benefits or exclusions, etc.  
 
9.2 Endorsements can be passed to amend or  include additional terms to the policy , 
so that the policy conforms to the legislative requirements.   
 
9.3 Endorsements can also serve as supplementary agreements that provide 
optional benefits not previously contained in the basic policy. Such benefits 
require a separate additional pre mium. Examples of such supplementary 
benefits are maternity benefits for attachment to a Hospital & Surgical 
Insurance polic y. Endorsements pertaining to supplementary benefits may be 
attached to the policy , when they are issued or they may be added at a l ater 
date. When added, they become part of the  policy . 
 
9.4 Endorsements on exclusions restrict the scope of coverage , by excluding a 
specific pre-existing condition or certain activities or avocations. The i nsurer 
may require this form of endorsement as a pre -condition for issuing a policy. 
This is one type of counter -offer. If the insured signs the endorsement and 
accepts the policy as offered, there is a binding contract. A copy of the signed 
endorsement remains attached to the policy.  
 
 
10. CONCLUSION  
 
10.1 As an insurance representative , you should help your prospective clients to 
understand the standard policy provisions  and terms , as well as to explain to 
them the endorsements attach ing to the ir polic ies. 

10. Common Policy Provisions  
Copyright reserved by the Singapore College of Insurance Limited [Version 1. 4]                                   245  
APPENDIX 10A 
 
POLICY SCHEDULE  
 
 
ABC Insurance Company  (Singapore)  Limited  
 
21 Any Street, ABC Centre, Singapore 654321  
Tel: (65) 6789 8181   Fax: (65) 6789 8282  
 
 
Policy Issue Date :                      POLICY SCHEDULE  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 TERRITORIAL  :   
LIMITS     
 
 
 
 
DETAILS OF POLICY  
Policy Number:  
Type  Of Plan:  
Sum insured/ Benefits:  
Policy Commencement Date:  
Policy Expiry Date:  
Premium:  S$ 
Endorsements: Nil  
 
 
 
 
 THIS SCHEDULE REFLECTS THE TERMS, CONDITIONS AND COVERAGE OF Y OUR INSURANCE POLICY, 
SUBJECT OTHERWISE TO THE STANDARD POLICY WORDING AND/OR ANY OTHER AMENDMENTS AS 
SPECIFIED IN THIS SCHEDULE.  
 
 
      NAME OF POLICY OWNER : 
      NRIC OF POLICY OWNER:  
      ADDRESS:  
 
Anywhere in the Republic of  Singapore, and 
elsewhere in the world for the purpose of 
travel, but not for any intended or booked 
medical  treatment overseas by the Insured 
Person.  NAME OF INSURED PERSON:  
NRIC OF INSURED PERSON : 
 
ADDRESS:  
  
    


36
COMMON POLICY PROVISIONS
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Sections of a Health 
Insurance policy contract• Policy Schedule.
• Insuring Clause & Definitions.
• General Conditions.
• Benefit Provisions.
• Exclusions.
• Claim Conditions.
• Endorsements.
Information contained in 
a Health Insurance policy 
scheduleThe policy schedule gives the specific details of the policy contract.
• Policy number;
• Effective date of cover;
• Expiry date of cover;
• Date at which the policy is issued;
• Contract currency;
• Name and identity number of the policy owner;
• Name, age, gender and identity number of the insured person;
• Name of insurance plan;
• Types of riders and the coverage limits (if any);
• Premiums for the insurance plan and riders;
• Coverage details on benefits limits or sum insured; and
• Special provisions/endorsements indicating the types of endorsements 
attached to the policy.
Insuring clause The insuring clause also known as the operative clause states the purpose of the 
policy and outlines the conditions under which the policy will pay. The insuring 
clause serves to:
• Describe the general scope of coverage;
• Provide any definitions required; and
• Set forth the conditions under which the benefits are payable.CHAPTER
10
Common terms under a Health Insurance policy
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Dependant • Spouse and children of the policy owner (or of the employee in the case of 
Group Insurance). 
• A spouse is typically defined as the person to whom the policy owner is legally 
married under the laws of the country. A spouse is no longer considered a 
dependant in the case of legal separation.


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• A spouse is typically defined as the person to whom the policy owner is legally 
married under the laws of the country. A spouse is no longer considered a 
dependant in the case of legal separation. 
• As for a child, he must typically be unmarried, under the age of 18 years, and 
principally dependent on the insured for support. This definition also includes 
the legally adopted children and stepchildren of the insured. Most insurers will 
extend the cover up to age of 18 or 25 years if the child is pursuing a tertiary 
education.
Insured/insured person • The insured person is the person covered by the insurance. The insured person, 
more often than not, is the policy owner.
Accident • An incident caused by accidental, violent, external and visible means. Note that 
some insurers may not have the “violent” requirement in their definition of 
“accident”
Hospital • Any lawfully operating institution which has 24-hour a day nursing services by 
registered graduate nurses, one or more physicians available at all times and 
organised facilities for diagnosis and major surgery.

37
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Any one disability • Disabilities resulting from illness or bodily injury and their complications arising 
from the same cause. However, if any subsequent disability arising after a 
specified number of days (e.g. 45 or 90 days, depending on the policy wording 
of the insurer) has lapsed following the latest discharge from hospital, then it 
shall be considered a new disability, regardless of the cause.
Covered charges • Charges incurred by the insured person, while the policy is in force, for a 
service, supply or period of confinement, which has been ordered or prescribed 
by a physician.  
Day of hospital 
confinement• Refers to a full 24 hours during a period of hospital confinement.
Registered medical 
practitioner/physician• Qualified medical practitioner registered with the Singapore Medical Council to 
render medical and surgical services. It excludes a physician who is the policy 
owner, insured person himself or his spouse or any of his lineal relatives.
Medically necessary 
service, supply or day of 
hospital confinementA service, supply or day of hospital confinement, which is ordered by a physician 
and which is:
• Provided for the diagnosis or direct treatment of a disability;
• Appropriate and consistent with the symptoms and findings or diagnosis and 
treatment of the insured person’s disability;
• Provided in accordance with generally accepted medical practices on a national 
basis;
• Most appropriate supply or level of service which can be provided on a cost 
effective basis; and
• Not of an experimental or investigative nature, or research purposes.
Period of hospital 
confinement• Continual period of time where an insured person is confined to a hospital as a 
registered inpatient.
• Two or more periods of hospital confinement resulting from the same or 
related causes, are considered as the same period of hospital confinement, 
unless the break between the date of discharge of the earlier period of hospital 
confinement and the date of admission of the following period of hospital 
confinement is more than a specified number of days (e.g. 45 days).
Pre-existing condition It is usually defined as a condition which has existed and:
• For which the insured person received treatment or medical advice;
• In respect of which the insured person showed symptoms;
• Of which the insured person was aware; and
• Of which the insured person should reasonably have been aware; 
before the date of policy issue or the date that the cover was reinstated.
Policyholder/policy owner • The policy owner owns the policy and is responsible for the payment of 
premiums and receipt of claims and benefits under the policy.  He has the right 
to make changes to the contract and receive all payments due under the policy.
Usual, customary and 
reasonableIt means the charges for a specific service, supply or period of hospital confinement:
• Is within standard charge for the specific provider; and
• Must not be more than the general level of charges of other medical care 
providers with similar standing in the same geographical area, for an 
equivalent treatment, services or supplies to individuals of the same gender, of 
comparable age, for a similar illness or injury.
Waiting period •  For Medical Expense Insurance , it refers to the period of time starting from the 
date of policy issue or reinstatement date, where the insured person's medical 
expenses are not covered by the policy. Waiting period differs from insurer to 
insurer and applies only to medical expenses arising from an illness, not from 
an accident.
• For Disability Income Insurance , it refers to a specified period of time, 
beginning with the onset of the disability, where benefits are not payable.


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• For Disability Income Insurance , it refers to a specified period of time, 
beginning with the onset of the disability, where benefits are not payable. The 
waiting period in a Disability Income Insurance policy is sometimes called the 
“elimination period” or the “probationary period”.
• For Long-Term Care (LTC) Insurance , it refers to a period of time beginning 
from the first day the insured person is unable to perform the specified 
Activities of Daily Living (ADLs), during which no LTC Insurance benefit will be 
payable. For LTC Insurance, this may also be known as the deferred period.

38
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Illness • Illness refers to a physical condition marked by a pathological deviation from 
the normal healthy state.
Pre-hospitalisation 
benefits• Refers to the diagnostic X-ray, laboratory tests and specialist consultation for 
an illness or injury which occurred within a specified number of days prior to 
hospitalisation. The insurer will pay only for such outpatient treatments if they 
lead to hospitalisation or surgical operation, within the time frame as specified 
in the policy.
Per policy year limit • Maximum amount that a Medical Expense Insurance (MEI) policy will pay for all 
the eligible medical expenses that an insured person incurs within each policy 
year.
Lifetime limit • Maximum amount that a MEI policy will pay for all the eligible medical expenses 
that an insured person incurs under the policy.
Deductible and co-
insurance• Deductible is a flat amount of covered medical expenses that an insured person 
must first incur, before the insurer will make any benefit payment under a MEI 
policy. This amount will have to be borne by the insured person.
• Co-insurance is a percentage of all eligible medical expenses, in excess of the 
deductible, that the insured person must personally pay under a MEI policy.
Pro-ration factor • Percentage that the insurer will use to pro-rate the hospital bills before it 
computes the claim payout, if the insured person is admitted to a ward/hospital 
higher than what he is entitled to under the policy.
General conditions sections that outline the 
rights of the policy owner and the insurer
IMPORTANT CONCEPTS DEFINITIONS/EXPLANATIONS
Entire contract clause • This clause states that the present contract, together with any specified 
attachments/endorsements, make up the entire contract, and no other 
documents form another part of the contract.
Effective date of cover • The effective date of cover is established in the policy by agreement between 
the insurer and the policy owner. It is the date on which the insured person 
begins to be covered under the Health Insurance policy.
Premium clauses • Individual Health Insurance Policies Issued By Life Insurers - When the 
policy is first incepted, the premiums must be paid before inception of cover. 
When the policy is renewed during the second year onwards, it is subject to a 
Grace Period whereby the premium must be paid within 30 days from inception 
of cover.
• Group Health Insurance Policies Issued By Life Insurers – Grace Period 
provision within such policies which states that the premium has to be paid 
within 30 days from the commencement date or renewal date (whichever is 
applicable); or the date of the insurer’s premium tax invoice, whichever is later.
• Health Insurance Policies Issued By General Insurers  – Subject to the 
Payment Before Cover Warranty  which states that the policy shall not be in 
force, unless the premium is paid to the insurer or intermediary on or before 
the date of inception of the policy.
• Group Health Insurance Policies Issued By General Insurers  – Subject to the 
Premium Payment Warranty which states that if the period of insurance is 
more than 60 days, the policyholder is required to pay the premium due under 
the policy in full, within 60 days from the date of inception of the policy. 
Free-look period • Period of time after delivery of the policy document during which the policy 
owner may review the policy and return it for a refund of the premium paid to 
the insurer (less any medical fees incurred)
Actively at work • Group Insurance  - It provides that an employee is not eligible for coverage, if 
he is absent from work because of an illness, injury and other reasons on the 
effective date of his coverage.
• Disability Income Insurance  - It provides that the cover will automatically 
terminate, when the person is not working owing to illness or termination of 
service.


