The Health March/April 2024 | Page 16

A surge in claim disputes due to scams is causing a delay in settling medical claims disputes

Industry

16 The HEALTH | March-April . 2024

Rising financial scams burden OFS

A surge in claim disputes due to scams is causing a delay in settling medical claims disputes

BY KHIRTINI K KUMARAN

THE increasing number of financial scams is putting a strain on the Ombudsman for Financial Services ( OFS ) to settle claims speedily .

Not only has the number of scams increased , the cases have become increasingly intricate , often involving multifaceted schemes . Inevitably , the resolution of other claims , such as medical claim disputes , is therefore affected due to staff shortages . It could take up to a year to resolve a claim if you ’ re unlucky .
OFS Chief Executive Officer Marina Baharuddin said investigating these scam cases requires additional time as it gathered supporting documents and evidence from various entities such as banks , e-money issuers , third-party merchants , telecommunication providers , etc .
“ These scam cases frequently involve unique and evolving methods employed by perpetrators . Thus , we must thoroughly comprehend the precise sequence of events and circumstances leading to the compromise of bank accounts , e-wallets , or cards ,” she told The Health .
To manage the rising workload , the OFS has recruited new personnel and continuously evaluated the need for additional staff .
OFS ’ s Client Charter commits to a prompt and fair dispute resolution , aiming for resolution within three to six months , subject to case complexity . However , only 48 per cent of the cases were resolved within six months .
Despite these challenges , Marina reassured that most medical and other insurance / takaful cases are typically resolved within six months . “ OFS continues to adapt , recruiting additional personnel to address rising workloads and evolving dispute complexities .”
To reach an impartial resolution , OFS must obtain all required information and relevant documents from the parties involved . While the aim is to resolve disputes within the stipulated timeframe , timelines may vary depending on the case ’ s complexity .
ADDRESSING TRENDS AND CHALLENGES
Regarding the dispute resolution of cases that extend beyond the six-month mark , Marina emphasised the diverse complexities inherent in each case . “ Some cases may necessitate extensive investigation or negotiations , leading to resolutions surpassing the six-month mark .
“ Certain cases may necessitate further investigation or obtaining documents , such as medical reports from government hospitals , which could extend the resolution timeline to up to 12 months .
“ We may seek a legal opinion where necessary . If the requested information is not provided within the specified timeframe ( 14
Marina Baharuddin
“ OFS is dedicated to continuously enhancing its processes and addressing customer feedback to ensure the optimal handling of medical claims .”
days / 30 days ), we may extend .”
With emerging trends and challenges in the medical claims landscape , OFS must navigate the complexities of coverage , medical necessities , and customer satisfaction .
Marina explained : “ For example , OFS has encountered challenges related to the interpretation of “ medically necessary ” clauses in insurance policies , particularly concerning the utilisation of specialised medications or procedures not sanctioned by the Ministry of Health .”
This ambiguity often leaves policyholders uncertain about their coverage and can lead to disputes between insurers , healthcare providers , and patients .
“ In response , proactive measures , including proposals to financial service providers ( FSPs ), have been initiated to enhance transparency and understanding .
“ By working collaboratively with industry stakeholders , OFS seeks practical solutions that benefit consumers and FSPs ,” Marina emphasised .
CONTINUOUS IMPROVEMENT AND CUSTOMER FEEDBACK
“ There has been a decline in medical cases referred to OFS over the past three years ,” said Marina , attributing to the improvement in the FSPs ’ internal complaint management .
“ While 182 disputes were reported in 2021 and 139 in 2022 , the number decreased to 111 in 2023 .
“ Based on the medical cases we have been handling , the FSPs have been very receptive to our approach and feedback .
“ OFS is dedicated to continuously enhancing its processes and addressing customer feedback to ensure the optimal handling of medical claims .”
Marina said OFS implemented various measures to improve processes , including regular reviews of existing procedures , ongoing staff training , and collaboration with industry associations and regulators .
“ Furthermore , OFS actively solicits and addresses customer feedback through annual satisfaction surveys and direct communication channels with complainants and FSPs throughout the resolution process .”
The OFS is a non-profit organisation regulated by Bank Negara Malaysia ( BNM ). The OFS was formerly known as the Financial Mediation Bureau ( FMB ) and commenced its operations in 2005 . For the record , FSPs are also members of OFS and some representa-