WHEN Hannah (not her real name) was diagnosed with Stage 1 breast cancer four years ago, she believed her health insurance would help ease some of the financial burden that came with the treatments. The 37-year-old underwent surgery, chemotherapy and radiotherapy, all of which were successfully covered under her medical insurance policy.
Her critical illness payout also came through without any issues.
The problem only surfaced later, during the hormone therapy phase of her recovery.
“I was told the hormone therapy would be covered, as it was part of my treatment.
“Looking back, I think there was a gap in understanding on both sides about what the policy actually covered,” she says.
Her insurer rejected her claim, categorising the hormone therapy as “preventive” treatment aimed at reducing the risk of recurrence, rather than part of the primary cancer treatment itself.
“Since my surgery, chemo and radiotherapy were considered the primary treatment, anything after that was seen as preventive, and preventive treatment is not covered under my plan,” she says.
With the help of her oncologist and insurance agent, Hannah decided to appeal the decision.
Her doctor also submitted a letter explaining that the hormone therapy was medically necessary rather than optional.
Despite the appeal, the insurer maintained its decision.
“The difficulty wasn’t the process. It was accepting the outcome,” she says.
Skipping the treatment was never an option to her, she says, but the rejection forced her to explore alternatives to manage the cost. She initially attempted to continue her treatment at a government hospital, but the process became complicated due to differences in treatment protocols and medication requirements.
“In the end, I went back to my usual oncologist at the private hospital. It hurt the pocket quite a bit, but that was the reality I had to work with,” she says.
In hindsight, Hannah says she wishes she had reviewed her insurance policies more regularly instead of assuming the coverage she purchased years ago would remain sufficient indefinitely.
“I bought it, I felt safe, and moved on. I didn’t realise how much the landscape could change, or that my coverage might not keep up with it,” she says.
She now advises others to ask more detailed questions before purchasing insurance, especially about how insurers define different forms of treatment.
“Not just ‘Am I covered?’ but covered for what exactly, and under what conditions? Under-stand what counts as treatment versus what’s preventive under your policy, because that distinction matters more than most people realise,” she says.
For Rahim (not his real name), 30, the confusion surrounding his insurance claim began not because his treatment was excluded but because he misunderstood how the claims process worked.
After breaking his arm in a car accident in Petaling Jaya, the technician assumed his insurance policy would immediately cover the surgery he needed. Instead, hospital staff told him he would first need to pay an upfront deposit before treatment could proceed.
“I was confused and angry.
“I was in pain, and now I need to reach into my wallet to pay for something first before I get my treatment?” he says.
At the time, Rahim believed this request for payment meant his insurance claim had been rejected. He only learnt later, after contacting his insurance agent directly, that the surgery was actually covered under his policy.
Instead, the issue stemmed from delays in processing the guarantee letter (GL), which private hospitals require before directly billing insurers.
“The coverage was valid all along, but the paperwork lag created unnecessary stress,” he says.
Rahim says the experience taught him the importance of understanding not only what a policy covers, but also how the claims process itself works during emergencies.
“I would tell other policyholders to always be prepared for the hospital’s admission process. Private hospitals often ask for an upfront deposit unless the insurer’s GL has already been issued. That doesn’t mean your insurance won’t cover you,” he says.
He now advises policyholders to familiarise themselves with their insurer’s panel hospitals, carry their medical cards at all times, and contact their agents immediately if issues arise during admission.
“Make sure you call your agent right away. Don’t wait for hospital staff to explain.
“Your agent can confirm coverage and push for the GL,” he says.
For both Hannah and Rahim, the experience revealed the gap that can exist between having insurance and fully understanding how it works in practice.
While their situations were very different, both say the experience highlighted the importance of asking questions, reviewing policies regularly and clarifying assumptions before a medical emergency happens.
