REJECTED or delayed insurance claims are not just administrative disputes between insurers and policyholders.
There is a third stakeholder in the process: doctors. Because such incidents can directly affect how quickly patients receive treatment or, in some cases, whether they receive it at all.
Malaysian Medical Association (MMA) president Datuk Dr Thirunavukarasu Rajoo says there is a concerning trend of patients being denied, delayed and turned away from treatment due to insurance claim disputes.
“We don’t have a national registry for rejected claims. That is itself a problem.
“What we do have are consistent reports from doctors in private practice, and the pattern is worrying,” he says.
According to him, doctors frequently find themselves caught between patient care and insurance processes, particularly when guarantee letters are delayed or disputed.
“When a guarantee letter is rejected or delayed and the patient is waiting or getting worse, the doctor still has to act.
“Duty of care doesn’t pause for an insurer’s decision,” he says.
In some emergency situations, he says doctors have proceeded with treatments despite uncertainty over whether the claims will eventually be paid.
This pattern cannot continue, he says, adding that the MMA is calling on Bank Negara Malaysia to require data on rejection rates, dispute frequencies and settlement timelines to be reported, analysed and acted on.
Internally, the MMA has already tried to do something about this.
“In 2019, we proposed a formal grievance mechanism for exactly these issues.
“That became the HPPSC (Healthcare Partners Protocol and Solutions Committee) – bringing together doctors, hospitals, insurers, takaful operators and third- party administrators, with the Health Ministry and Bank Negara as observers.”
For the patients, rejected or delayed claims often create immediate financial and emotional strain, he says.
“Self-pay means finding money fast – loans, borrowing from family, delaying the procedure.”
Patients who cannot afford private healthcare may instead turn to public hospitals, where waiting periods can be significantly longer depending on the urgency of the condition.
“A patient waiting for a hernia repair or joint replacement can wait months.
“He is in pain. His condition can worsen.
“What was elective becomes an emergency.
“That was preventable. The only thing that stopped timely treatment was money,” says Dr Thirunavukarasu.
The doctor is also affected, he adds, because when they see such patients, they know the delay was caused by a coverage dispute and not clinical necessity.
“That stays with you.”
As such, he says, the impact extends beyond finances.
With the base medical and health insurance and takaful (MHIT) framework being prepared for roll out, The Star previously reported that while the MMA supports the intent behind the plan, it also warned that affordability reforms must not come at the expense of treatment quality, specialist access or patient flexibility.
Meanwhile, Dr Thiruna-vukarasu acknowledges that confusion over claims often stems from exclusions involving pre-existing, congenital or hereditary conditions, particularly when someone fails to fully disclose their medical histories during the application process.
However, he argues that people do this because they fear insurers will impose exclusions or higher premiums.
“The fear is not unreasonable.
“It is a direct response to how some insurers have priced and structured their products.
“Insurers are in the business of covering risk. That is what they are paid to do.
“A product designed to avoid anyone with a real medical history is not insurance; it is premium collection from the healthy,” he says.
While the MMA’s stance is to advise everyone to declare everything when they buy a policy, he questioned the insurance industry on whether their products are accessible to Malaysians with health conditions or only to those unlikely to ever claim.
“Policy language must also be written for the policyholder, not the insurer’s legal team. That has to change,” he adds.
Many consumers across all education levels do not fully understand their policies, but this is not purely a consumer problem, says Dr Thirunavukarasu.
“These are complex products, and the consequences only become clear at the worst possible moment.
“The licensed financial planner must do more than sell. They must sit with the client, explain what is covered, what is not, and what to do when a claim arises.
“You cannot sell on benefits and hide behind fine print when the claim comes in.”
