Monday, February 26, 2007

Foreign Doctor Policy- SMA ( sort of) responds

Hi friends,

I am glad that the Singapore Medical Association has finally responded to the Ministry of Health’s plan to import foreign doctors on an unprecedented scale over the next few years.

Such policies will affect the medical profession in a profound way and all in the profession must stay engaged.

I would imagine that if such colossal policy changes were to be mooted in any major democracy, there would have been much public debate.

But in Singapore, which is ironically eyeing a seat on the high table of advanced developed countries, it is rare that we get any comments from associations which purport to represent the medical fraternity.

Hence I am pleasantly surprised to find that Dr. Wong Chiang Yin, President of Singapore Medical Association has actually responded ( in a way) to the Ministry’s position.

So.. enjoy


Dr.Huang Shoou Chyuan

From the SMA Newsletter
(read original article here)

The Better Doctor

By Dr. Wong Chiang Yin, President Singapore Medical Association

20 Years Ago

20 years ago, in 1987, I stumbled out of my army camp as a private in training to attend the Medicine Interview held in the three seminar rooms outside level two of the Medical Library. I was assigned to Team B, chaired by the late Professor of Medicine,Chan Heng Leong.

One of the more memorable exchanges during the interview was this:

“What do you read in your free time?”

“Scientific American.”

“Are you saying that because you think we like people who read Scientific American?”

“No. I actually read that because I like it. I also read MAD magazine.”

I then promptly fished out my copy of Scientific American and MAD magazine and showed the panel.

Another memorable question was: “There will be too many doctors when you graduate. In
fact, there are probably already too many doctors now. What would you do after you graduate from medical school, if you find that you are unable to get a job that would allow you to practise

I replied: “If you are really a bad doctor, you may not get a job even in good times. But then
again, even in bad times, there is always a job for the better doctor.”

I guess that was not really a bad answer for me; maybe it was a bad answer for the medical
profession, because since then, the profession has been stuck with me.

A Foreign Doctor Convert

Recently, a senior (local) doctor working in the polyclinic commented to me over dinner that
she felt the relevant authorities were treating NTS (non-traditional source) doctors unfairly.
She felt that the NTS doctors were up against changing goal-posts. (NTS doctors are doctors
with basic degrees from universities which were not registrable with SMC). These doctors were
“promised a lot” when they were recruited and now with changing policies, it appears they would be asked to leave, when their current temporary SMC registration expires, after they have settled down here with their families. It appears that they were told that they would be given conditional registration if they obtained the GDFM, but now the bar has been raised to the M.Med.

I do not know if there was any truth to these allegations by her but nonetheless, I was surprised at this remark from her because I remember a few years ago, she was complaining to me about
the quality of NTS doctors and the intense supervision they required. Well, it appears that her
opinion of NTS doctors has changed quite a bit. According to her, the quality of the first NTS batch of doctors was patchy. The current ones were good – they realise the “precarious” position they are in with regard to their SMC registration and they work hard and make the extra effort to be good polyclinic doctors.

I then said if they were good, then they should have no problems passing either the GDFM or the M.Med. To this she replied: “You know, they may be good doctors, but they are not drilled like us since young to pass exams. Our M.Med exam is not easy to pass unless you are exam-oriented.” I will not argue with her on this. She was a far better student than me in medical school. But this incident does illustrate how a previous cynic of having foreign doctors here has been persuaded to believe that they are good for our healthcare system.

Recently, the Minister for Health announced his intention to bring in more foreign doctors. This has drawn reactions from quite a few local doctors, GPs and specialists alike. Several have written to SMA and asked us what SMA is doing to protect the local doctors’ livelihoods. One private sector cardiologist called me as if the world has ended for him.

Avoiding Character Assassination

My own personal belief is this: If SMA is not protectionist, then appearing protectionist when you believe otherwise is hypocritical. If SMA is protectionist, then in Singapore’s context,
appearing protectionist may be the worst way to actually forward the protectionist cause. In other words, appearing protectionist may be the worst way forward whether SMA is protectionist or not. Because once you are labelled successfully as protectionist, you can be pretty sure that whatever you say afterward will not be taken very seriously. To be labelled as protectionist is to be successfully character-assassinated.

For the record, the current SMA council is not protectionist. Having said that, protecting local doctors’ livelihood is different from being protectionist. For example, the local legal profession is actually facing a decreasing number of litigators despite more law graduates and now has to think of a way of making lives for litigators more bearable and litigation a more palatable career option.

The same thinking can be applied to the local GP scene where while there is no decrease in numbers, there are certainly more and more GPs turning to non-traditional areas of GP work to supplement their income.

The Minister for Health has also been reported to be saying that he wants to double the number of doctors in hospitals, from having one doctor for every two beds to one doctor per bed.

More Doctors – Who Pays?

The Minister for Health has also been reported to be saying that he wants to double the number of doctors in hospitals, from having one doctor for every two beds to one doctor per bed.

What are the possible outcomes if doctors were indeed to be doubled in our hospitals?

Let us assume an extreme scenario whereby despite the increase in doctors, the foreign patient
load does not increase and all the additional doctors see only the same number of local patients.
That would mean that each doctor has double the amount of time per patient. That is a good thing for the patient. Unfortunately, the downstream effects in extreme situations would be:

a) the pay of each doctor is halved, or

b) each local patient pays double the amount he would have previously paid for the same
amount of physician services, or

c) supplier induced demand sets in and the doctor doubles the amount of physician services
needed by one patient.

I do not believe for a moment that the relationship between doctors’ income and number of doctors is linear: that doubling number of doctors will lead to each doctor earning only half of what he used to. The likely scenario is that all of the above will occur to some limited extent (that is, decrease in doctor’s pay, increase in healthcare inflation and supplier induced demand), unless a large part of the capacity generated by these additional foreign doctors will be used by foreign patients, which is unlikely. Foreigners will take up some of the additional capacity but domestic consumption will still take up the majority of the increase in capacity afforded by foreign doctors.

That leaves us to ask – who pays for the new services provided by these doctors to the local
population? The quick answer is Singapore will pay because another country is certainly not paying for the health services consumed by us. And how will this be paid? Simply put, the bill has to be either paid for by the government (more taxes?) or the people in one way or the other. Singapore has traditionally adopted the policy that the people should take responsibility for their health and therefore for most of the healthcare costs incurred. Hence in Singapore, Government Health Expenditure (GHE) only takes up about 1/3 of Total Health Expenditure (THE). This can be seen in Table 1 where Singapore is compared to developed countries and our neighbours. Singapore’s GHE is only 36.1% of THE and this is low when compared to other developed countries and some neighbouring countries as well. In the absence of a means test, one can argue that accessibility of healthcare to the poor will be compromised if this percentage drops further. Even in free-market USA, where 1/6 of the population does not have access to healthcare except at emergency departments, the government takes up a higher proportion of THE (at 44.6%). If Singapore goes any lower than 36.1% (and without a means test), it will probably have to contend with the poor having problems availing themselves to healthcare,
similar to countries such as India, China, Indonesia and Vietnam with a low GHE as a percentage of THE. In fact, in all likelihood, the government’s share of THE in Singapore may actually increase if the trend seen in other developed countries is anything for us to go by, especially so when we do not have a means test to direct and focus GHE toward the poor and needy.

Singapore’s percentage of GDP spent on healthcare is also on the low side when compared to
other developed countries. With an aging population and rising expectations, this figure will have to likewise go up to levels of most other developed countries (that is, between 7% to 10%).

In other words, the new capacity created by an influx of foreign doctors (should this influx take place at all) will not be only at the expense of local doctors’ income but will have to be funded at least commensurately by an increase in GHE and THE as well.

Looking at the table, Singapore’s Physician per 1,000 Population is indeed low by developed
country standards. The point to be made here is that the shortage of doctors in Singapore is selective and there is a mal-distribution of workload between the public and private sectors which exacerbates the effects of shortage. We certainly do not need more GPs, obstetricians and so on. And if we pay renal physicians and geriatricians a whole lot less than some popular surgical disciplines or what these same specialists can get in the private sector, then we will never get enough local doctors specialising in renal medicine or geriatrics, and even if we do get more of them, we cannot get them to stay in the public sector where most of the work is done.

Table 1: Selected Countries and, THE as
Percentage of GDP, GHE as Percentage
of THE and Physician Density

Australia 9.5 67.5 2.47 (2001)2
Canada 9.9 69.9 2.14 (2003)2
China 5.6 36.2 1.06 (2001)2
France 10.1 76.3 3.37 (2004)2
Germany 11.1 78.2 3.37 (2003)2
India 4.8 24.8 0.60 (2005)2
Ireland 7.3 78.9 2.79 (2004)2
Japan 7.9 81.0 1.98 (2002)2
Netherlands 9.8 62.4 3.15 (2003)2
New Zealand 8.1 78.3 2.37 (2001)2
South Korea 5.6 49.4 1.57 (2003)2
Switzerland 11.5 58.5 3.61 (2002)2
UK 8.0 85.7 2.30 (1997)2
USA 15.2 44.6 2.56 (2000)2
Singapore 4.5 36.1 1.56 (2005)3
Indonesia 3.1 35.9 0.13 (2003)2
Malaysia 3.8 58.1 0.73 (2003)4
Thailand 3.3 61.6 0.37 (2000)2
Vietnam 5.4 27.8 0.58 (2003)4

No Compromise in Standards

Another point to be made really is why would foreigners want to come here? As history has shown, it is very difficult to convince top clinical talent to come to Singapore. The proviso here being we need to be clear about what constitutes top talent. Our notions and definitions of talent must never be allowed to be compromised for the sake of making up the numbers (for example, to make up one doctor per inpatient). The standards expected of foreign doctors must be at least as high as those expected of the local doctors, if not higher. A level playing field is the basic requirement for local and foreign doctors to have a good chance of co-existing harmoniously.

It is commonly known that at least half the graduates of famous schools in China and India such
as Peking Union Medical College and All-India are offered jobs in the West before or soon after they graduate. Will there be any significant numbers from these top schools left for Singapore? And once good foreign doctors are allowed into Singapore, we also need to address the equally important issues of objectively assessing these doctors and to get them to leave Singapore if they are found to be wanting.
We can learn from the experiences of other sectors such as banking and the corporate world and so on, where foreigners are free to work here and also have been made to leave quickly when found wanting.
Exit management – getting the unsatisfactory ones out – is as important as getting them in, that is, recruitment.

Steps Forward

In summary, I would like to add that while allowing more foreign doctors into Singapore may
seem ominous to some of us in the profession, I take the view that it is not only just the doctor’s
livelihood that is at stake. At stake are also the equally important issues of health inflation, supplier induced demand etc and the overall competitiveness and efficiency of our healthcare services. The current macro-equilibrium between accessibility, affordability and quality can go either way with more foreign doctors. It is not a risk-free policy or path to take. So frankly, there are other people who should (and I hope would) be worrying about this more than doctors.

The problem for the SMA is that at the microlevel (that is, the individual level), there will be
doctors who will feel the negative effects of the winds of change. It is our duty as the national medical association to go out and help prevent this or at least prepare them for this. To this end, the SMA Private Practice Committee will be running a series of seminars and courses to help our members. For a start, we will restart our seminar on “Starting Private Practice”. This was a seminar that was very popular a few years back. We also develop further courses that we think will help the private sector doctors to optimise their practices financially and operationally.

20 years later today, I still believe that there will always be a job for the better doctor. And a
reasonably well-paying one too.

1. 2003 Statistics from WHO, (accessed 29 January 2007)
2. Year statistic obtained given in parenthesis
3., (accessed 29 January 2007)

Dr Wong Chiang Yin is the President of the 47th SMA Council and Chief Operating officer in a public hospital. When not working, his hobbies include photography, wine, finding good food, calligraphy, going to the gym and more(non-paying) work.

Friday, February 23, 2007

Doctor numbers- WHO statistics

1.WHO Statistics on Number of doctors per capita by countries
(NB: the doctor figures from different countries may be from different years- as reported to WHO)

Countries/ Drs Nos./ (Dr. numbers per 1000 )
Singapore 5,747 (1.4) )

Europe (Advanced countries)
Belgium 46,268 (4.49)
Denmark 15,653 (2.93)
Finland 16,446 (3.16)
France 203,487 (3.37)
Germany 277,885 (3.37)
Ireland 11,141 (2.79)
Italy 241,000 (4.2)
Netherlands 50,854 (3.15)
Norway 14,200 (3.13)
Sweden 29,122 (3.28)
UK 133,641 (2.3)

North America
USA 730,801 (2.56)
Canada 66,583 (2.14)

Oceania-Asia Pacific
Australia 47,875 (2.47)
NZ 9,027 (2.37)
Japan 251,889 (1.98)
S Korea 75,045 (1.57)
Malaysia 16,146 (0.7)
Philippines 44,287 (0.58)

Other City States
HK 11505 (1.7)
Taiwan 34093 (1.52)

Addendum: 24.2.07 HK and Taiwan's statistics I just got from


2.My comments

Hi Friends,
I manage to get the statistics for Doctor numbers and Doctors per capita ( ie per 1000) figures from the WHO website.

I do not have the time to analyse the figures yet, but it is pretty much self-explanatory.

I do not want to give a knee-jerk reaction to the Ministry of Health's sudden disclosure that we have about the advanced nations' lowest doctor-population ratio ( now suddenly we count ourselves amongst the 1st world! Anything to win an argument?) .

Anyway, the statistics do not lie. ( but then again wasn't it Disreali who said, " There are 3 types of lies- Lies, damned lies and statistics" ?)

But somehow, my impression and my doctor-friends impressions also do not bear out that we are short ( esply in the private sector).

I wonder how being a city-state skew the stats? I wonder what would the doctor per capita of cities be? Any statisticians or maths whiz out there? I just added in HK's and Taiwan's figures.
Theirs are closer to Sg's numbers ( but still a tad higher).

Let's chew on the statistics ( and dig up your books on t-test/ chi-square test/correlation coefficient etc) and let me have your comments.


Dr.Huang Shoou Chyuan

PS: I apologise for the poor quality of graph ( I did it with my elementary MS Excel skills all by my lonesome self)

Also the figures keep bunching up. Given up trying to space and line them out.

3.About the WHO website for statistics (Core Health Indicators)

For those who want to look at the statistics yourselves please go:

Then select (all countries)---> (all years)

select physicians ( numbers) and physician per capita.

Then of course press submit ( in case there are technology virgins here) :)

4. This is the thingaling that started the whole debate

Singapore has worst patient-doctor ratio: report
(21 Feb 07

Singapore has the worst patient-to-doctor ratio among developed countries and has embarked on a global effort to entice doctors, a report said Wednesday.

Top health ministry officials went to Australia and London last year to convince Singaporean doctors studying or working there to return, and to encourage top foreign doctors to practise in Singapore, the Straits Times said.

It quoted the health ministry's permanent secretary Yong Ying I, who was dispatched to London last year, as saying Singapore has the worst patient-to-doctor ratio among developed countries.

"We have very efficient doctors and they work very hard. But somewhere along the way we also don't have enough," the newspaper quoted Yong as saying.

"If you want to bring down waiting times, we need to recruit more doctors, much more than a few percent."
The city-state is faced with an ageing population but is also seeking to bolster its role as a top provider of quality healthcare services for patients from abroad.

Singapore, Southeast Asia's most advanced economy, had a population of about 4.4 million with 6,748 doctors registered in 2005, according to official statistics.

The goal is to have one doctor per patient in public hospitals, up from a ratio of one per every two, the report said.

The country needs to produce 400-600 locally trained doctors annually, up from the current level of more than 200, the paper quoted Health Minister Khaw Boon Wan as saying.

Khaw cautioned that "much as we will try to recruit as many as we can, we will be lucky to half-succeed," which was why he sent his top two ministry officials to scout for doctors abroad, the report said.

Sunday, February 18, 2007

Education- Be fair to alternative routers and lifelong learners

Hi Friends,

Gong Xi Fa Cai!

Mark Twain said, “I have never let schooling interfere with my education.”

Education does not stop with schooling- in fact, sometimes education has nothing to do with schooling.

Education is a life-long process.

My observation is that in the past many Singaporeans stop substantial learning after attaining their professional or vocational qualifications.

This mindset is slowly changing and nowadays, thousands of students enroll for courses from the many private educational colleges scattered throughout our city.

Students who take alternative routes

Many who enrolled for the bachelor programmes are polytechnic diploma holders who feel that a degree will give them a leg-up in their careers and others are post-A levels students who have missed out on places in the local universities.

A small majority are actually degree holders considering mid-stream changes in their career paths. Some rare ones, like me, are just bored or are undergoing mid-life crises (partly joking). I attended the University of London external degree programme at the Stansfield College in 2005-6.

Many private colleges, of varying reputation, host programmes from UK/Ireland, USA and Australia. Most of these colleges have sound management although we had a few negative examples like Informatics which left bad tastes on many students’ mouths.

Truth be told, I had a economics lecturer, MH, who was one of the best lecturers I have ever had for any subject, ( and I assure you I have studied many subjects in my 40-something years). He obviously has a passion for teaching Economics( and also loves a good smoke). The last I heard he has left Stansfield- a real shame.

About the UOL external degree

The most well-known programme is of course the University of London-external degree programme.

Most employers may not know that the UOL examinations in the external degree are of the same standard as the ones taken in London. In fact, candidates sit for them on the same day (as in London) but the two sets of papers have some variations to prevent cheating. More importantly, the papers are scored by the same pool of markers.

So, for all intense and purposes, any successful candidate in Singapore would have passed if he had taken papers in London.

My ex-classmates (and me) spent as much as three nights a week and struggle through very difficult examinations in May, and yet often not get the recognition that they deserve.

Yet, Singaporeans and employers, in particular, frequently hold in disdain degrees attained through part-time studies.

Prejudice against alternative routers inexplicable

Singaporean society has an inexplicable prejudice that says any knowledge not obtained through mainstream educational institutions ( ie 3 local universities and certain branded overseas Uni’s) are not worthy of recognition.

My personal conviction is that life is a journey of continuous learning and if these alternate route students are so motivated to overcome their perceived lack of paper qualification by sacrificing good time and money, they should be rewarded instead of being penalized!

Granted most can and do complete formal education in an uninterrupted spurt (with hiatus for National Service in the case of boys), a substantial minority need more time (sometimes due to extenuating circumstances beyond their control).

I hope all employers look beyond the paper and more into the potential employees' motivations and abilities.

I cannot speak for the other courses/programmes, but there is no reason why they should be sub-standard.

About the Post Secondary Education Accounts ( Budget 2007)
(see link)

I am obviously delighted that Tharman (2nd Minister of Finance) has seen fit to top up post-secondary students’ account up to the tune of $400.

This,I am happy to note, includes the UniSIM (the 4th university) which caters mainly to alternative routers that I was ranting about above.

But $200-400 too low and mere token

However, the amount ($200-400) is tokenistic and is a mere drop in the ocean for these students who have to fork out more than $20000 for a 3 year degree (UOL).

Also other private colleges which offer the same programmes offered by UniSim are excluded.

This is clearly unfair. These students suffer a double jeopardy.They already pay higher fees than NUS/NTU/SMU and are yet not even given the few token bucks.All post-secondary students regardless of institutions should be allowed to cash these tokens.

In the meantime, I guess private colleges like Stansfield, SIC and others competing directly with UniSIM would have to discount at least the same amount to retain their students.This will hit their bottomline.


I hope that all employers,esply the civil service- Singapore’s largest employer, would keep an open mind and judge each employee by his/her contribution and potential and not by the route taken to obtain that paper.

Better still, look beyond the paper! Help correct the obsession with the paper chase.

NB: BTW,I have moved on and am in an MBA programme. (That is the subject of another post)

Saturday, February 10, 2007

Brain death case at SGH (HOTA)

Dear Friends,

Human Organ Transplant Act (HOTA) has been in place since 1987 and ammendments made to it in 2004 .

Link to MOH Hota page ( read it - don't be lazy)

To put it simply, HOTA initially consisted only of cadaveric (dead person) donation of kidneys from accidental death ---> cadaveric donation ( kidneys) from any death (not just accidental)---> cadaveric donations of kidneys+liver+heart+cornea --->living donor ( relative only) --->living donor ( non-relative) but only if no emotional coercion and financial inducement ( ie not organ for sale scenario) . Muslims are exempted.

It is an opt-out system : If you don't bother to opt out, it is Presumed that you have agreed.

Very easy to opt out, just download a form or get it from the usual places and sign it.

HOTA is law

Whether we agree to it or now, it is now the law of the land.

There is much controversy about HOTA, including:

1.Overall issue about organ transplantation (religious objection etc)
2.Opt-in system: Is it fair? ( taking advantage of apathy)

The Case in question

The tragic Mr Sim case shows how little Singaporeans take control of their lives.

Most of us care 2 hoots about anything ( ok, we can blame society for a stressful and dogeatdog lifestyle). We have been conditioned ( or undergone socialisation) to leave nearly everything to the government. We have almost abdicated the right to decide on all aspects of our lives.

The family of Mr Sim Tee Hua is understandably grieving and certainly don't need additional stress from anyone, esply police and medical personel.

but Police and Medical Personnel are just doing their job

But the policemen and medical staff are in a lose-lose position. They have to carry out their jobs and yet risk being labelled as "unfeeling and inflexible". Of course, all concerned can be more tactful, communicate more effectively etc. But no amount of tact will completely alleviate the grief that the Sim family is going through now.

If there were more delays, the organs would be of no use to anyone. We are already short of these organs.

Diagnosis of Brain Death (FAQ Min of Health)

There are clear guidelines for the diagnosis of "Brain Death" and the people on the panel responsible for this dreaded diagnosis of Death are not connected to the organ transplantation team and hence have no vested interest in the whole procedure (to avoid conflict of interest.)

As much as we sympathise with the grieving family, let us have a thought for these public servants. Don't make it harder for them to carry out their duties ( unless you want to be in their shoes)

What can we do if you don't agree with HOTA ( or any law)

Instead of attacking the messengers ( these public servants), those who are against HOTA (or any law) should try to get it changed/rescinded. I know most say it is futile to try to change any law in Singapore but we never know till we've tried.

Anyway, the majority of Singaporeans have elected this government and what it stands for. So we get what we deserve ( but that's a subject of another post)

I am not against HOTA. It is better than commercialised organ trading ( some say HOTA may a be disguise for organ trading in the non-related donor scenario).

Dr.Huang Shoou Chyuan

Two samples of letters to the forum about this case ( 10th Feb 07 ST forum)

Letter One:
'Brain-dead man's kin in scuffle over op to remove organs' (ST, Feb 8)

THE report, 'Brain-dead man's kin in scuffle over op to remove organs' (ST, Feb 8), shows clearly that there is much to be done to educate the public on the Human Organ Transplant Act (Hota), as amended in July 2004.
The public must be made aware that kidneys, livers, hearts and corneas suitable for transplant can be removed from all Singaporeans and permanent residents upon their death as defined by the Act - unless they have opted out.
Hospitals and polyclinics should be in the forefront, explaining to patients Hota whenever the opportunity to do so arises.
The various community institutions can also help in educating the public at the grassroots level.
This will prevent the tussle the relatives of Mr Sim Tee Hua had with the hospital staff because they would have known that Hota will kick in in such circumstances and would also be aware of the window of time needed for transplants.
Alternatively, hospitals can, whenever they anticipate the possibility of enforcing Hota, pre-empt any outburst by making the patient's relatives aware that the organs will be removed upon confirmation of brain death.
This must be done with the utmost sensitivity.
Harry Chia Kim Seng

Letter Two

SGH could have handled removal of organs better

READING the article, 'Brain-dead man's kin in scuffle over op to remove organs' (ST, Feb 8), the Singapore General Hospital came across as rather unfeeling in its handling of the situation.
The man's mother and five relatives kneeled and begged the doctors not to remove his kidneys and corneas, to no avail. His family was not convinced that he was really dead as his body was still warm.
Yes, the hospital was carrying out the procedure under the
Human Organ Transplant Act (Hota) but, surely, the matter could have been handled better.
On one hand there is this family reeling from shock over the death of a loved one and, on the other hand, there is the law, in the form of surgeons and nurses bent on removing all his useable parts.
Where is the compassion and humanity that are so clearly lacking?
Many people are still unaware that their organs can be taken away from them unless they opt out.
To avoid such heartrending confrontations. I suggest that the Ministry of Health educates Singaporeans and permanent residents that unless they opt out, under Hota their organs will be removed once they are considered brain dead.
The ministry should also make opt-out forms more readily available - and also available online - so that people do not have to go hunting for this vital form in clinics and hospitals.
Dr Lim Boon Hee

Monday, February 05, 2007

Aviva Insurance- Having the cake and eating it?

STRAITS TIMES - Jan 31, 2007

'Pre-existing condition' strikes out cancer patient's insurance claim

Plan excludes coverage, but some rival firms say they would have paid

By Finance Correspondent, Lorna Tan

A 45-YEAR-OLD woman diagnosed with breast cancer thought her medical bill was covered by her insurance policy, but a rude shock awaited her.

Backed by medical reports, her insurer Aviva said that the 9cm lump found in her breast had begun growing before her policy took effect.

It refused to pay, saying her cancer was a pre-existing condition at the time that she signed up for her MyShield hospitalisation policy - never mind that she had no idea at the time.

Fortunately for Ms Simone Vaz, her company has paid for the bulk of her medical bills. She also managed to receive payouts from two critical illness policies, one of which she had signed up for at the same time as her MyShield plan.

Still, her case has turned the spotlight on an often-overlooked but vital issue in medical insurance - the definition of a pre-existing condition.

And the details of Ms Vaz's case underline the complexity of the question and the differing approaches of insurers in dealing with the question.

She signed up for a MyShield plan with Aviva here in January last year and it took effect on April 1. Based in Shanghai, Ms Vaz works as a communications manager at a telecommunications firm.

She was not required to take a health test by Aviva. Prior to that, the last time she had a health check was in 2004 when she applied for her China visa. Ms Vaz had never undergone a mammogram prior to the diagnosis.

The first indication that something was amiss occurred during a spa massage in Shanghai in mid-June last year when she experienced pain.

She saw a doctor in Singapore and was diagnosed as having advanced or 'stage three' breast cancer. The tumour in her breast was removed immediately at Mount Alvernia Hospital.

Her initial medical bill of $15,000 was rejected by Aviva on the grounds that\nthe condition existed before her policy was issued."

Aviva backed this up with medical opinion.

In a letter to Ms Vaz's lawyer, Aviva stated that independent medical specialists had advised that it would have taken three to nine months for the tumour to grow to 9cm from 1cm.

Ms Vaz's claim was rejected not because of non-disclosure on her part.

It was rejected because the Aviva plan excludes all pre-existing conditions regardless of whether there is disclosure or non-disclosure or whether the insured has knowledge of the condition.

Its 'pre-existing condition' clause states that 'any injury, illness, condition nor symptom which originated...prior to the policy commencement date whether or not treatment, or medication, or advice, or diagnosis was sought or received' is excluded under the policy.

When contacted on the rationale for its policy, Aviva's chief executive, Mr Keith Perkins, said that by having an objective evaluation on when an illness originated, it is protecting the interests of the majority of its policyholders.

This guards against potential abuse which may lead to higher premiums if claims go up. 'If we rely on what customers know, we'll never know,' said Mr Perkins.

Aviva receives about 5,000 MyShield claims per year and less than 1 per cent of\nthese claims are rejected because of pre-existing conditions.

Currently it has nearly 100,000 MyShield policyholders.

An insurance adviser told The Straits Times that Aviva's policy may come as a surprise to many medical insurance policyholders.

They probably assume that if they are unaware of a given condition at the time they sign up for the insurance policy, they would be covered, he said. And most of the time, they would be right.

A Straits Times check with rival insurers AIA, Great Eastern (GE), NTUC Income and Prudential found that they adhere to this principle and would have paid Ms Vaz's claim.

The clauses of GE and Prudential are similar. Prudential's clause states that a pre-existing condition is the existence of any signs or symptoms for which treatment, medication, consultation, advice or diagnosis has been sought or received by the life assured or would have caused an ordinary prudent person to seek treatment, diagnosis or cure, prior to the cover start date of this benefit or the date of any reinstatement'."

GE added in response to queries about Ms Vaz's situation that even if the doctor were able to estimate how long the condition had existed, it 'would not be fair' on the policyholder if the insurer declined the claim.

The clauses of AIA and Income are similar to each other, but more ambiguously phrased. AIA's clause states that 'any pre-existing illnesses, diseases, impairments or conditions from which the insured is suffering prior to the policy date...will not be covered', without specifying if the policyholder needs to be aware that he is suffering from the illness.

However, both insurers told The Straits Times that if a policyholder is genuinely unaware of a medical condition which is diagnosed only after the policy inception, they would pay the claim. AIA added that the insured must not have any symptoms at the time he took up the policy.

Aviva's Mr Perkins disagreed with that approach, maintaining that an independent medical opinion is crucial for an 'objective evaluation of claims'.

A clause based on customers knowing about an illness cannot be objectively evaluated as it relies on us knowing customers' personal knowledge,' he said.

'I'm not concerned that we're different from other insurers. I'm happy that we are.'

Ms Vaz said Aviva's pre-existing condition clause put an insured person 'at a complete disadvantage'. Her bills have skyrocketed to more than $70,000 due to the operation, chemotherapy and radiation sessions.

She added that her fear was that her health care would suffer due to a lack of finances when she retires or if she is retrenched.

Aviva gave her an ex gratia payment of $3,128 which she has not cashed in yet.

When contacted, a Ministry of Health spokesman said that private insurers can choose to impose additional exclusions on their Shield plans should the insured have any pre-existing illnesses.

The Consumers Association of Singapore (Case) executive director Seah Seng Choon said that in his view, the clause is 'not fair' to customers if they are genuinely unaware and have no intention of omitting information on a medical condition."

He added that if there is such a clause, the insurer should stipulate the timeframe for such pre-existing conditions and highlight the requirement to the consumer
(NB: Bold and italics are mine)

My comments:

Dear friends,

Aviva said: “Ms Vaz's claim was rejected not because of non-disclosure on her part.It was rejected because the Aviva plan excludes all pre-existing conditions regardless of whether there is disclosure or non-disclosure or whether the insured has knowledge of the condition.”

I feel the burning need to comment as it seems that Aviva’s policy-holders are in a severely disadvantaged position.

You Pay premium but Aviva may not pay when you send in claim

Even if one signed up with Aviva in good faith, not hiding any knowledge of any pre-existing medical conditions, Aviva can refuse to pay.

This is preposterous as even now, the body of knowledge about the Causes ( etiology) of Cancer is still very rudimentary. The theories of Cancer include, genetic predisposition,viral,environmental plus plus. ( a lot of time they mean "I don't know")

When a patient (let’s call him Joe) consults his regular doctor ( let’s call him Dr.Good) today (5th Feb 07), not even the most expensive test in the world, can say with 100% certainty that Joe does not have any cancer cells in his body.

Assuming Joe says, “Dr.Good, I am interested in buying insurance next week and I want to be sure that I am fit and have no pre-existant illnesses so as not to be accused of defrauding the insurance industry. Can you help me?”

Dr.Good, who is friendly and methodical ( but sensible and prudent), says,” Of course I can. Do you have any illnesses like hypertension, diabetes, history of family illnesses etc etc)
Because I am a good doctor, I will send some blood specimens for baselines checks and do an ECG.

BTW,I don’t think you need the expensive PET scan. Anyway, the Minnistry of Health, advises against using PET Scans as a screening tool unless absolutely warranted”

As expected, Joe passes the tests with flying colours and happily signs up with Aviva the next week. ( Boy- is Joe in for a surprise!!)

If 6 month’s later, Joe goes to see an ENT Surgeon, lets call him Dr.Me, and is diagnosed with early nose cancer and requires radiotherapy etc, Aviva can refuse to pay, citing the possibility of pre-existing cancer when Joe signed up.

It matters not that Joe and Dr.Good had vouched that they thought Joe was clear of cancer on the 5th Feb 07.

Even Dr. Me on the day of diagnosis cannot be certain at all how long the tumour had been there. It is all just guesswork and conjecture on the doctors’ part.

Now, Aviva is in a very enviable position.

If it does not want to pay- based on whatever reason, it can just get opinions from doctors and then use these opinions (and I remind you that these are just opinions ), to avoid the responsibility of paying! Some specialist on Aviva's panel- if forced to commit, could have said that " it is not inconceivable that some cancer cells could have existed prior to Feb 07" or something to that effect.

Have the cake and eat it! How nice and convenient!

Salma Khalick agrees with Aviva!??

(ST: 5th Feb 07) Salma Khalik: Aviva did the right thing in rejecting cancer claim- ( read here for article)

In my opinion ( yes that word again), Aviva is wrong. Salma is just as wrong to sanction Aviva’s actions.

She mentions motherhood truths about why buying insurance early is better and why one should be responsible for one’s own healths etc. What has all that to do with Ms Vaz’s case?

Ms Vaz, bought insurance which she thought would help her when she contracts some dreaded illness later on. It is a tragedy that she finds herself with an unexpected cancer.

The sense of tragedy is compounded now that Aviva has found some excuse not to fulfil its obligations.

Any action from anyone?

Some regulatory bodies and consumer advocacy groups should be looking into this!

I will be buying magnifying lens to pour over the fine prints in my insurance policies!

Dr.Huang Shoou Chyuan