KUALA LUMPUR: Insurance and takaful operator (ITO) companies and Third Party Administrators (TPA) do not have the authority to determine treatment and patient care, Deputy Finance Minister Lim Hui Ying says, emphasising that this remains the exclusive responsibility of doctors.
“If the recommended treatment is not covered under the insurance policy, the payment may be settled directly by the patient,” she told the Dewan Rakyat on Thursday(Nov 6).
She explained that TPAs and ITOs have the responsibility to review and manage claims of policyholders according to the terms and conditions of their contracts.
This includes verifying whether the claims fall within the scope of procedures covered under the policy and if they are medically necessary.
“This review is conducted solely to confirm coverage eligibility and to determine whether a claim may be made based on commonly accepted treatment protocols, based on the clinical practice guidelines, including those issued by the Health Ministry,” she said.
In cases where the treatment provided does not follow the usual treatment protocol, the ITO will conduct a further review to understand the clinical justification for such treatment. If the treatment is found to be medically necessary, the claim must be paid.”
This process is crucial to control medical cost inflation, which may arise from wastage and misuse within the healthcare system,” she added.
She said industry data has shown that ITOs have maintained their approval rate for claims at above 90%
Nevertheless, she said that the government, Bank Negara Malaysia, and industry players have established a Grievance Mechanism Committee.
This committee serves as an industry platform to address operational and business practices, such as reducing delays in issuing guarantee letters and reviewing disputed cases, particularly those involving treatment costs that must be paid.
She was responding to a supplementary question by Sim Tze Tzin (PH-Bayan Baru) on insurer interference in clinical decisions, withdrawal of guarantee letters, and rejecting claims on the basis that they are not in compliance with protocol, among others.
The Star reported on Nov 5 that ideal cancer treatment options for insured patients are being delayed, with insurance companies ignoring clinical needs and dictating terms, including downgrading medical procedures.
It was previously reported that a TPA had issued a directive concerning the use of anaesthesia for daycare surgical cases.
Health news portal Code Blue recently ran a report based on a poll surveying 855 specialists nationwide, which found that almost all of them perceived that health insurers had violated their clinical autonomy.
