#1 YOU DIDN'T HAVE THE ORIGINAL DOCUMENTATION 🤭
Insurance companies will always require these documents and they are:-
Claim form
Original receipt
Original invoice/ breakdown of items
Medical Report (sometimes may not required if it’s a follow-up consultation)
If you’re unable to provide item #a to #c, they may not honor the claim.
#2 YOU DIDN’T GET PAID 😡
Insurance companies will only pay to the policy holder’s account regardless of who pays the bill. And if a child is parked under a parent name, be sure to have the other spouse registered as a “contingency assurance” in case one of the parents passes away, the parent still can get their claims.
#3 YOU DIDN’T KNOW WHAT ARE NOT COVERED 😓
Items that are not covered in a hospitalization claims are:-
Medical Report
Supplements
Medication that is out of scope of your admission (For example, I had a client who did a stent for his heart, and because of his sugar level, the doc also changed his diabetic meds, so the diabetic meds wasn’t covered as it is not part of the cost/cause of admission in the first place)
Special request for extra meal/ extra bed
Upgraded room rate above your medical card entitlement
Co-insurance - the amount that you and the insurance company co-share the hospital bill (may be min. 300 to a max amount of 10% of the hospital bill)
Regular Medical check ups that does not required admission
GP visit / outpatient visit for cough/ flu and fever/ mild allergies and consultations that doesn’t required you being admitted
Covid test required prior to admission
Hospital administration fee
Health screening test that were recommended by the doc but totally unrelated to the treatment required
You have exhausted the medical limit (Policy renewal limit is not based on calendar year but based on the ate of approval for your policy anniversary)
Your coverage has expired/ lapsed because you didn’t pay your premium
Either you or the agent didn’t declare your health when first you sign up
The hospitalization was caused by unlawful incident (I.e drunk driving/ accidents because of you were participating in a dangerous sport)
#4 YOU DIDN’T KNOW THE WAITING PERIOD 🤥
Any newly minted policy or upgraded top up on existing policy are subjected to a 30 - 120 days waiting period. I got a client who did a top up on Dec 2019, but was admitted for chest pain, and got his medical card downgraded to his original coverage. An investigation was done after his admission and found that this was not a non-disclosure circumstance and was revert back to the upgraded plan.
#5 YOU WISH YOU KNOW WHAT ARE COVERED IN CLAIMS 💆🏻♀️
OUTPATIENT DAY CARE SURGERY
Examples of outpatient day care surgery like endoscopy/ stent, basically procedures that don't require you to stay in the hospital. These procedures require you to stay in the hotel for a min. 6hrs. And usually the hospital can apply for a guarantee letter a week before the procedure.
PRE & POST HOSPITALIZATION
Example, I had a client who had a fall and hurt his back, went to the GP and was given pain killers, however after 4-5 days the pain persisted. The GP issued a referral letter to the hospital, and was admitted for a slip disc surgery. After staying in the hospital for 4days, he needs to go for Physio and follow up.
So in the case above, the policy holder was able to claim from the insurance company for:-
GP visit (provided the receipt clearly writes the diagnosis + referral letter)
Follow up visit up to 60 or 90 days after discharge depending on the policy term
Admission in hospital were covered in the medical card
MINOR ACCIDENTAL INJURY
Minor accidental injury such as falling down from a bike/ a sprain/ cut that doesn’t require hospitalization but only seek treatment in a clinic is claimable up to a max amount of RM2,000 to RM5,000 per injury and based on the policy terms & conditions. It is based on reimbursement basis, so the doc will need to write a diagnosis on the receipt in order to fulfill the claim requirement
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