Medical Insurance Claim Guide For Malaysians

Need to file a medical insurance claim, or just curious how it works? Here’s what you need to know.

Why do I need to make a medical claim? Can I just use my medical card?

In an ideal world, we would only have to wave our medical cards to get medical attention, without having to pay for hospital bills. Well, it works that way… in certain scenarios.

Some insurance policies are cashless policies, where you can present your medical card upon admission to an approved hospital. The hospital will authenticate your details with the insurer, who will issue a letter of guarantee after confirming that you meet the terms and conditions of the policy. This letter guarantees that your insurer will cover your hospital costs, allowing you to be admitted without having to pay the hospital bills yourself.

However, this does not always happen. You may need to pay your hospital bill in advance if:

  • You do not have a cashless insurance policy. Some policies are reimbursement policies, which will require you to pay hospital bills first before claiming reimbursement later.
  • You were treated by a non-participating doctor or in a non-convention hospital. If your doctor or hospital is not covered by your policy, you will need to pay your hospital bills first and file a medical claim after discharge.
  • You were treated abroad. You may not be able to use your medical card abroad. However, depending on the terms and conditions of your policy, you may be able to request a refund.
  • Your insurer has not issued a letter of guarantee. If, for whatever reason, your insurer does not issue a letter of guarantee, you can prepay and file a medical claim after your discharge.

What should you do before getting treatment?

Before receiving elective treatment, contact your provider or insurance agent. This could clear up any confusion or disappointment that may arise if you try to claim treatment that is not covered by your policy.

Also, bring your medical card so that your hospital can arrange for your letter of guarantee to be issued, if required.

How to make a medical claim

Complaint procedures vary depending on your provider, but the process generally goes as follows:

Step 1. Prepare the required documents

The documents required may vary depending on your insurer and policy, so it’s best to check with them first. You will usually need to prepare the following documents:

  • A photocopy of your NRIC/passport
  • Original hospital receipts and bills
  • Itemized Hospital Bills/Itemized Bills
  • Any diagnostic report (blood test, coronary angiogram, x-ray, etc.)
  • For treatment abroad: copies of passport, boarding pass, flight ticket details, original detailed invoice (and English translation, if necessary)

Step 2. Complete the required claim forms

To obtain claim forms, contact your insurer or download a copy from your insurer’s website. Depending on your policy, your doctor may need to complete a medical examiner’s statement, which is a medical report that provides your insurer with more information about your diagnosis and treatment.

Step 3. Revise and make copies

Check your documents to make sure everything is in order. It is a good idea to make copies before submitting your application. You may need to consult with them if there are any complications with your application.

Step 4: Submit your claim

Submit your claim to your agent or the branch of your insurer. Some insurers will also allow you to submit them online. And that’s all! Although you should be careful when collecting all the necessary documents and filling out the forms, the process is quite simple.

While you wait for your claim to be approved, you can check the status of your claim by contacting your agent, calling your insurer’s customer service department, or emailing your insurer.

If your application for medical insurance is denied, can you appeal?

Go through your policy terms again and review the forms you submitted to see if everything is in order.

If you believe that your request has been wrongly refused, you can file a complaint with your insurer’s complaints department. And if that fails, you can seek help from the PIAM Information Center (PIC) and the Financial Services Ombudsman (FSO). Consumers who hold an insurance policy with a PIAM member provider can obtain assistance from PIC and OFS in resolving disputes related to insurance matters.

Do not be too long

We know that dealing with paperwork is a real headache, but you will have to submit your application within a given time; usually within 30 days of treatment. If you miss this window, your application may not be approved. A successful claim could mean the difference between being able to cover your treatment costs and being saddled with medical debt, so it’s best not to delay.

This article was first published in July 2019 and has been updated for freshness, accuracy and completeness.

Read more:
How to apply for travel insurance in Malaysia
How to make a car insurance claim

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