The health insurance pre-authorisation backlash could spark real reform

Health insurance pre-authorisation—meant to verify medical necessity before an insurer foots the bill—is quietly turning into one of the most divisive issues in Singapore’s healthcare space. Long treated as little more than a formality, the process is now coming under fire from doctors, patients, and policymakers alike. Their core complaint? That this layer of administrative control is not just slowing care, but chipping away at clinical autonomy and public trust.

In a country often lauded for its healthcare efficiency, this kind of pushback is rare. But as insurers—particularly those managing Integrated Shield Plans (IPs)—tighten their grip to manage rising healthcare costs, tensions are beginning to surface in visible, and increasingly vocal, ways. This piece unpacks why pre-authorisation is drawing heat now, who’s most affected, and what the escalating backlash might signal for the future of healthcare financing in Singapore.

In Singapore, pre-authorisation mostly crops up in the context of private insurance claims—especially when patients tap into higher-tier IP riders. Want to be admitted to a private hospital or undergo a specialist procedure? You’ll likely need your insurer’s blessing before coverage kicks in. Insurers frame it as a safeguard: a way to control spiralling costs and weed out over-servicing. On paper, it’s a due diligence check—a pause to confirm necessity before paying out. In practice, however, that pause can drag. For doctors and patients alike, it often feels like an obstacle course made of paperwork, phone calls, and guesswork.

The delays aren’t just irritating—they can be clinically disruptive. Some private specialists say they’ve had procedures questioned or redirected based on insurer preferences. “It feels like we’re losing control of the patient journey,” says Dr Raymond Chua, a senior consultant in private practice. And he’s not alone.

The clampdown on pre-authorisation didn’t appear out of nowhere. After COVID, insurers were staring at steeper claims and renewed pressure to keep premiums affordable. According to Ministry of Health data, IP claim sizes surged by 20% between 2017 and 2021—partly due to greater use of private hospitals and specialist-led care.

That spike set off a wave of recalibrations. To rein in claims, insurers began rolling out more stringent controls: co-payments, step-down care incentives, and, notably, stricter pre-authorisation rules. Names like AIA, Prudential, and Great Eastern all now enforce prior approval for a broader swathe of high-cost procedures.

It’s a strategy with logic—but it’s not without fallout. Reports have emerged of surgeries being pushed back, or treatment plans being tweaked to match what’s insurer-approved rather than what’s clinically ideal. Patients caught in this web feel increasingly disempowered. Online, the backlash is gaining traction. On forums like HardwareZone and Reddit Singapore, frustrated users ask questions like: “Why is my insurer deciding my treatment instead of my doctor?” It’s a fair question.

What began as a process problem is now morphing into something bigger—a trust issue. On paper, pre-authorisation promises clarity and cost control. But in the real world, it’s stoking suspicion. Doctors are beginning to wonder: are these policies still rooted in medical logic, or are they being written by cost-cutting consultants? Some warn of a slippery slope toward US-style managed care, where insurers don’t just reimburse—they shape treatment choices.

Patients, particularly those with chronic or complicated conditions, often find themselves stuck between medical advice and bureaucratic red tape. Even when the green light finally comes, the wait alone can be stressful enough to erode confidence in the system. That limbo—when a diagnosis hangs in the air but treatment is paused—can be psychologically draining.

As for insurers? Every delay, denial, or dispute becomes a reputational risk. In a competitive market where private plans are sold on the promise of convenience and peace of mind, appearing to block care—even inadvertently—is a branding liability.

To date, the government has largely let the private insurance market self-regulate. But with complaints stacking up, industry insiders are beginning to call for clearer boundaries. Some ideas are already in circulation. One: set mandatory response times—48 hours, say—for all pre-authorisation decisions. If the clock runs out, approval is granted by default. Another: standardise the list of treatments that require prior sign-off, so providers know what to expect and can plan accordingly.

A few insurers are experimenting with AI-driven portals and real-time authorisation platforms. It’s a step in the right direction, but speed alone won’t rebuild trust. Doctors want to know their clinical judgment still counts. Patients want to understand why something is denied—and by whom. Moving forward, the system will need more than technology. It needs shared principles: that medical decisions shouldn’t be overridden by finance teams, and that care delays are an exception, not a feature.

This isn’t just a debate over red tape. It’s about the future of Singapore’s hybrid healthcare model. That model rests on a delicate equilibrium: public subsidies for foundational care, supplemented by private insurance for those who want faster or more personalised options.

But if private insurers start looking more like gatekeepers than enablers—if choice starts to feel conditional—faith in the system may start to erode. That’s a problem, especially as Singapore moves toward initiatives like Healthier SG, which emphasize personal responsibility and long-term health ownership. With an ageing population and chronic care needs on the rise, flexibility and responsiveness will only grow in importance. Insurers who meet those needs—by simplifying approvals and respecting clinical authority—will earn loyalty. Those that don’t risk regulatory intervention or mass customer migration.

What’s unfolding around pre-authorisation isn’t background noise—it’s a reckoning. Stakeholders are pulling in different directions, and the tension is beginning to show. While cost discipline is essential, it can’t come at the expense of care integrity or patient dignity.

No one’s arguing for a free-for-all. But the current model needs a reset. Faster decisions, clearer rules, and an honest appeals process could restore some badly needed balance. And this doesn’t need to be adversarial. With the right nudges—light-touch regulation, aligned incentives—the government could help nudge the system back on course.

If Singapore wants to keep its mixed model resilient, private insurance must remain an asset, not a liability. That means restoring trust, aligning on purpose, and remembering who the system is ultimately built for: the patient.