Clinical decisions remain in the hands of doctors, not insurers or third-party administrators (TPA), says Deputy Finance Minister Lim Hui Ying.
She said the role of insurance and takaful operators (ITO) as well as TPAs is limited to assessing claims based on policy terms.
“If the recommended treatment is not covered under the insurance policy, the payment may be settled directly by the patient,” she added.
She said TPAs and ITOs are responsible for reviewing and managing policyholder claims according to the terms and conditions of their contracts.
This includes verifying whether the claims fall within the procedures covered under the policy and whether they are medically necessary.
In cases where a treatment does not follow the usual protocol, she said the ITO would conduct further review to understand the clinical justification. If the treatment is found to be medically necessary, the claim must be paid.
Lim said industry data shows that ITOs have maintained their claim approval rate at above 90%.
She said the government, Bank Negara Malaysia and industry players have set up a Grievance Mechanism Committee to address operational and business issues, including reducing delays in issuing guarantee letters and reviewing disputed cases, particularly those involving treatment cost payments.
She was responding to a supplementary question from Sim Tze Tzin (PH-Bayan Baru) on insurer interference in clinical decisions, withdrawal of guarantee letters and rejected claims due to non-compliance with treatment protocols, among others.
On Wednesday, The Star reported that ideal cancer treatment options for insured patients were being delayed, with insurance companies dictating terms and downgrading medical procedures.
It was also reported that a TPA had issued a directive concerning the use of anaesthesia for daycare surgical cases.
