Singapore legislation
Regulation 13
Regulation 13
Claim limits
Subregulation 1
Subject to paragraph (1A), the total amount of claims that may be paid under an insured person’s MediShield Life cover in respect of each insurance period is an amount not exceeding an insurance period limit of —
$100,000, if the insured person was admitted before 1 March 2021; (b)$150,000, if the insured person was admitted on or after 1 March 2021 but before 1 April 2025; or
$200,000, if the insured person was admitted on or after 1 April 2025.
Subregulation 1A
Any claim for the administration of an approved CTGTP is not subject to the limit mentioned in paragraph (1).
Subregulation 1B
For the purposes of reckoning the total amount of claims paid under an insured person’s MediShield Life cover in respect of an insurance period, any payment made for a claim for the administration of an approved CTGTP is not to be included.
Subregulation 2
Subject to paragraphs (1) and (3A), an insured person is entitled to claim under the Scheme, for each approved outpatient treatment received before 1 June 2026, the lower of the following amounts:
an amount determined in accordance with the following formula:T × P × 0.9,where Pis the pro-ration factor specified in the Fourth Schedule applicable to the insured person in relation to the type of approved outpatient treatment received by the insured person; andTis the total amount of the charges payable for the approved outpatient treatment received by the insured person; (b)the total of the assured amounts for approved outpatient treatment received by the insured person.
Subregulation 2A
[Deleted by S 323/2026 wef 01/06/2026]
Subregulation 3
Subject to paragraphs (1), (3A), (4A), (7) and (7B), an insured person is entitled to claim, under the Scheme, for each approved medical treatment or services that is a specified claimable medical treatment or services (called the current claim), an amount ascertained by applying one of the following formulae to the approved medical treatment or services:
if A is not more than $5,000, the formula is —[(A − B) × 0.9] − C;
if A is more than $5,000 but not more than $10,000, the formula is —[($5,000 − B) × 0.9] + [(A − $5,000) × 0.95] − C;
if A is more than $10,000, the formula is —[($5,000 − B) × 0.9] + ($5,000 × 0.95) + [(A − $10,000) × 0.97] – C,where Ais the sum of —
the relevant amount for the approved medical treatment or services to which the current claim relates; and
the relevant amount for all other approved medical treatment or services —
with an admission date during the same insurance period as the approved medical treatment or services to which the current claim relates; and
in respect of which a claim was received by the Board before the current claim was received;Bis the lower of the following:
A;
the insured person’s contribution for the approved medical treatment or services to which the current claim relates; andCis the sum of all claims paid for all other approved medical treatment or services referred to in sub‑paragraph (b) of the definition of A.
Subregulation 3A
Any claim for repetitive transcranial magnetic stimulation treatment is subject to the following conditions:
an insured person is only entitled to claim for 2 courses of repetitive transcranial magnetic stimulation treatment in the insured person’s lifetime;
an insured person is only entitled to claim up to the following number of treatment sessions of repetitive transcranial magnetic stimulation for the first course of treatment:
where the insured person has received 24 or more treatment sessions for the first course of treatment before 1 June 2026 — 24 treatment sessions;
where the insured person has not received more than 23 treatment sessions for the first course of treatment before 1 June 2026 — 30 treatment sessions;
an insured person is only entitled to claim for a second course of repetitive transcranial magnetic stimulation treatment if the second course of treatment starts at least 120 days after the last treatment session of the first course of treatment;
an insured person is only entitled to claim up to the following number of treatment sessions of repetitive transcranial magnetic stimulation for the second course of treatment:
where the claim is made before 1 June 2026 — 15 treatment sessions;
where the claim is made on or after 1 June 2026 — 30 treatment sessions.
Subregulation 4
Subject to paragraph (4A), an insured person is entitled to claim, under the Scheme, for each claimable medical treatment or services (other than approved in-patient palliative care) received as an in-patient of any approved community hospital (called community hospital treatment), an amount calculated in accordance with the formula specified in paragraph (3), if —
the insured person has received claimable medical treatment or services as an in-patient of an approved medical institution and, on the insured person’s discharge from in-patient treatment provided by the institution, an approved medical practitioner of that institution certifies in writing that the insured person requires the community hospital treatment; (aa)a medical practitioner treating or assessing the insured person at the emergency department of an approved restructured hospital certifies in writing that the insured person requires the community hospital treatment; (ab)the insured person has received MIC@Home treatment provided by an approved medical institution, and an approved medical practitioner of that institution certifies in writing that the insured person requires the community hospital treatment; or
the Minister approves the person’s claim for the community hospital treatment.
Subregulation 4A
Paragraphs (3) and (4) do not apply to any claim for the administration, before 1 June 2026, of a CTGTP or a high-cost drug, but apply to any claim for ancillary medical services received, before 1 June 2026, in relation to the administration of the CTGTP or high-cost drug.
Subregulation 5
Subject to the claim limits in paragraphs (1) and (3), where, in connection with an organ transplant to an insured person, the insured person —
is admitted to any approved permanent premises of an approved medical institution as an in-patient for any claimable medical treatment or services; or
receives any day surgical treatment in the approved medical institution,the insured person is entitled to claim under the Scheme, as part of the charges incurred for such treatment, the amount of any organ transplantation costs that the insured person has incurred in connection with the organ transplant.
Subregulation 6
Despite anything in these Regulations, for the purposes of paragraph (5), where the organ transplantation costs are incurred in connection with a living donor organ transplant of which the insured person is the recipient of the specified organ, the assured amount for any item of claimable medical treatment or services applies separately in relation to —
the claimable medical treatment or services as received by the insured person; and
the claimable medical treatment or services as received by the living organ donor.
Subregulation 7
In paragraph (3), “relevant amount”, in respect of approved medical treatment or services that is a specified claimable medical treatment or services, is the lower of the following amounts:
an amount determined in accordance with the formula T × P, where —
P is the following pro-ration factor applicable to the insured person:
where the approved medical treatment or services are received by the insured person as an approved outpatient treatment — the pro-ration factor specified in the Fourth Schedule applicable to the insured person in relation to the type of approved outpatient treatment received by the insured person;
where the approved medical treatment or services are received by the insured person as an in-patient, under the MIC@Home programme, or as day surgical treatment — the pro-ration factor specified in the Fifth Schedule applicable to the insured person in relation to the type of approved medical treatment or services received by the insured person; and
T is the total amount of the charges payable for the approved medical treatment or services received by the insured person;
the total of the assured amounts for such approved medical treatment or services.
Subregulation 7A
Subject to paragraph (7B), an insured person is entitled to claim, under the Scheme, for the administration, before 1 June 2026, by an approved medical institution of an approved CTGTP, whether as an in-patient or outpatient, the lower of the following amounts:
an amount determined in accordance with the formula T × P × 0.9, where —
P is the pro-ration factor specified in the Fourth Schedule applicable to the insured person; and
T is the total amount of the charges payable for the approved CTGTP received by the insured person;
the total of the assured amounts for the approved CTGTP received by the insured person.
Subregulation 7B
An insured person is entitled to claim for only one course of treatment of the approved CTGTP for each applicable indication in the insured person’s lifetime.
Subregulation 7C
Subject to paragraph (1), an insured person is entitled to claim, under the Scheme, for the administration, before 1 June 2026, by an approved medical institution of an approved high-cost drug, whether as an in-patient or outpatient, the lower of the following amounts:
an amount determined in accordance with the formula T × P × 0.9, where —
P is the pro-ration factor specified in the Fourth Schedule applicable to the insured person; and
T is the total amount of the charges payable for the approved high-cost drug received by the insured person;
the total of the assured amounts for the approved high-cost drug received by the insured person.
Subregulation 8
In this regulation —
Definition
“applicable indication”, in relation to an approved CTGTP, means a clinical indication specified in the CTGTP List corresponding to that approved CTGTP;
Definition
“assured amount”, in relation to each item of approved medical treatment or services received by a person insured under the Scheme, means the amount specified in the Sixth Schedule in respect of that item of approved medical treatment or services;
Definition
“insured person’s contribution”, in respect of any approved medical treatment or services, means the amount of the insured person’s contribution specified in the Seventh Schedule in respect of the approved medical treatment or services received by the insured person;
Definition
“specified claimable medical treatment or services” means any claimable medical treatment or services received from an approved medical institution —
as an in-patient, under the MIC@Home programme, or as day surgical treatment; or
as an approved outpatient treatment, on or after 1 June 2026.
Subregulation 9
This regulation applies subject to regulations 14 and 20.