Preventing 'slowness' in insurance compensation - Part 3: Agents 'soak' files, customers wait wearily

When the family decided to file for an insurance claim for their bedridden wife, they were shocked to discover that the insurance agent had been holding onto the claim file for five years without submitting it to the company.

The patient was accompanied by family members to undergo a health assessment procedure, after suffering a stroke and paralysis for many years - Photo: BONG MAI

After receiving no insurance compensation for his wife's paralysis and inability to stay bedridden, the family decided to file a claim for his wife after consulting with a professional. They were surprised to discover that the insurance agent had been holding onto the claim file for five years without submitting it to the company.

It's worth noting that during the 5-year period when the customer is bedridden, their family members still have to pay the normal insurance premiums.

When the insurance claim was reviewed, the insurance company refused to refund the premiums that the customer's family had paid over the past five years.

The agent held onto the insurance company's records for 5 years without submitting them.

Early in the morning, amidst the crowded throngs at Nguyen Trai Hospital (District 5, Ho Chi Minh City), Mr. Hong held a stack of medical records, his wife being pushed in a wheelchair by their daughter-in-law, as they inquired about the procedures for assessing their disability percentage.

Sharing with us after his wife went inside to see the doctor, Mr. Hong said that his wife had suffered a stroke 5 years ago. She is paralyzed on the left side of her body, bedridden, has memory loss, facial asymmetry, and high blood sugar.

At that time, the family reported the patient's condition to an insurance agent named Hoang Anh. This agent visited the patient and took all of the patient's medical records. Some time later, the insurance agent informed them that the patient had suffered a stroke and was not eligible for insurance compensation.

After years of suffering injustice, and with guidance from a professional, Mr. Hong recently decided to file a claim for compensation for his wife. It was only then that Mr. Hong was shocked to learn that the agency had been holding onto the case file for five years without submitting it to the company.

According to data gathered by reporters, during a conversation with the insurance agent, Mr. Hong questioned why the agent did not submit his wife's medical records to the insurance company when she first fell ill, despite having collected them himself.

The agent explained: "Because I sent it, but yours didn't include critical illness coverage (...), so we didn't make the payment. That means it only included 'Lifetime Peace of Mind' coverage." The conversation ended because the agent said they were out and would call back later.

In another exchange, he and his daughter also asked why the client's medical records weren't being forwarded to the company. The agent gave several reasons, as already researched and "asked above," including the fact that the client hadn't purchased supplementary products – health insurance.

"It keeps demanding things back and forth, requiring all sorts of medical examinations," the insurance agent said, then added, "If I could do it, I would have done it for you; it's company money." The insurance salesperson added, "We've had many such cases here already."

Customers face difficulties in claiming insurance.

According to the insurance salesperson, "I only take responsibility when a risk occurs and I don't receive the money," then he gave an example of a case where a customer died and their family received the insurance compensation quickly. "We've been living together ever since," the insurance salesperson asserted, emphasizing their relationship and urging Mr. Hong and his family to trust him.

"The insurance saleswoman and her wife are friends; they're not very knowledgeable and lack expertise. I had no choice but to accept what the salesperson said, but I felt very resentful. Being bedridden with illness, not only do I not get any compensation, but I also have to keep paying insurance premiums. How can I bear that? I'm furious!" Mr. Hong said angrily.

After years of treatment, luck came in early 2024 when his wife gradually recovered, her face becoming somewhat more alert. However, she remained weak, required a wheelchair, needed diapers to urinate, and frequently forgot about her loved ones.

Following the Tuoi Tre newspaper's report on the incident, Prudential Insurance Company issued a referral letter for Mr. Hong to take his wife for a medical examination. By the end of November 2024, five years after the incident, the medical examination agency determined that the customer suffered 82% bodily injury, meeting the conditions for receiving permanent total disability benefits.

In response to Tuoi Tre newspaper in mid-December 2024, Prudential stated that based on the medical assessment results, the company had agreed to pay the customer the full and permanent disability benefit (100 million VND).

In a recent conversation, the insurance agent stated that she considers Mr. Hong's wife like her "older sister," and their relationship is as close as that of blood relatives.

The person admitted, "My mistake was not submitting the medical records. I was wrong, and I acknowledge my mistake." The insurance agent expressed a desire for a swift and peaceful resolution, hoping for a break so they could celebrate Tet (Lunar New Year), as the constant back-and-forth calls from the insurance company would hinder their business.

Regarding the complaint that an insurance agent received documents five years ago but failed to submit them to the company, affecting customer rights, Prudential responded to Tuoi Tre newspaper: "The company has received the complaint, and the relevant departments are coordinating to resolve it, with the motto of putting customers first and in compliance with the law."

Mr. Hong is going through the procedures to claim insurance benefits for his wife, who suffered a stroke and has been paralyzed for many years - Photo: BONG MAI

The business is responsible when the dealer makes a mistake.

Based on Article 128 of the 2022 Insurance Business Law, if an agent violates the contract, causing damage to the legitimate rights and interests of the customer, the insurance company is still responsible for fulfilling its obligations as agreed in the insurance contract arranged and concluded by the agent.

According to Article 129, the agent is responsible for reimbursing the insurance company for any amounts that the company has paid to customers due to the agent's misconduct.

For a patient with long-term paralysis, the insurance company is demanding additional proof.

Five years after the incident, Prudential has officially decided to pay out insurance benefits of 100 million VND to Mr. Hong's wife (Ho Chi Minh City).

However, the customer also requested that the company refund 50 million VND in insurance premiums paid over the past 5 years, along with accrued interest, because the customer suffered a stroke in mid-2019.

Regarding this refund issue, Prudential stated that during the discussion, the customer and their family explained that the customer had been severely paralyzed (bedridden) since 2019.

However, to date, apart from the assessment results (for which the aforementioned payment decision has been made), Prudential has only received a summary of the medical record extracted on June 7, 2019, which does not describe the extent of the customer's injuries upon discharge: the degree of paralysis, or the percentage of disability.

Therefore, the company will notify the customer about the review of the claim/application after the customer submits additional detailed medical records from Thong Nhat Hospital in 2019. Furthermore, the company "will also endeavor to gather more detailed information from the medical records regarding the customer's injuries for further assessment to ensure the customer's legitimate rights are protected in accordance with the insurance benefit payment principles."

Based on the medical record summary (dated June 7, 2019) received by the reporter, in the section summarizing the disease process and clinical course, the hospital recorded: A 64-year-old female patient was admitted to the hospital due to sudden weakness on one side of the body accompanied by difficulty speaking, left-sided hemiplegia, facial asymmetry, and high fluctuating blood sugar levels.

Summary of diagnostically valuable paraclinical test results: right ventricular infarction, occlusion of the right anterior cerebral artery segment A2. Treatment plan: follow-up examination when medication is finished, physical therapy.

The agent wants to refund the insurance premiums out of pocket.

In a recent conversation, the customer's daughter questioned whether the reason the company didn't refund the fee (50 million VND, paid since her mother suffered a stroke and became paralyzed, not including interest) was because the agent told the company that her mother was in good health.

The daughter emphasized that her mother had been paralyzed for several years, and after a long period of treatment, "she's only now feeling a little better." The insurance agent explained that the reason the company hadn't refunded the premiums paid over the past five years was due to a clause in the contract, not because of the daughter's words.

In December 2024, the insurance agent expressed a desire to compensate, meaning they would pay back 50 million VND from their own pocket. However, Mr. Hong's family did not want to receive the money from outside sources; they only wanted to follow the official procedure, which is receiving the money directly from the company.

Source: https://tuoitre.vn/ngan-chay-i-boi-thuong-bao-hiem-ky-3-dai-ly-ngam-ho-so-khach-mon-moi-cho-20250108224329487.htm