March-April . 2024 | The HEALTH

In 2023 , The OFS received 194 disputes encompassing Life insurance , Family Takaful , and General Medical insurance categories . Of these , 111 cases ( 57 per cent ) were related to medical and hospitalisation claims .

The majority of the medical claim disputes were on :

• Policy exclusion

• Non-conformance with policy terms and conditions

• Non-disclosure / misrepresentation of material facts in the insurance / takaful application / renewal

T���STA�� DIS��T� RESOLUTION PROCESS

In medical claims management , transparency and efficiency are paramount to ensure fair resolutions for all parties involved . OFS adopts a meticulous two-stage dispute resolution process to provide a fair and efficient mechanism .

“ Before a case is formally registered and handled at the first stage , complaints are screened by the Consumer Engagement and Analysis department to ensure they fall within OFS ’ jurisdiction and monetary limits ,” explained Marina .

Once a complaint is deemed eligible , it enters the first stage , Case Management , where a dedicated case manager is assigned to each dispute .

The case manager is a liaison between the parties involved , guiding them through the resolution process . The case manager ’ s role is to encourage dialogue , facilitate communication , and assist the disputing parties in clarifying their interests and understanding any differences in opinion .

“ The case manager may conduct the resolution through negotiation , mediation , or conciliation to reach a mutually acceptable settlement between the disputing parties within three months of receiving the full documents .”

Should parties fail to resolve , the case manager issues a recommendation within 30 days . However , this recommendation is not binding . Either party can escalate the matter to the second stage , adjudication , where an independent Ombudsman reviews the case and issues a final decision .

The Ombudsman conducts an independent review of the dispute , considering all evidence and arguments afresh . Within a swift timeframe of 14 days , the Ombudsman issues a final decision .

“ If the complainant accepts the final decision , it is binding on the complainant and the FSP . If the complainant does not accept the decision , the disputing parties can pursue their rights through other means , including

legal process or arbitration .”

FAIR AND TIMELY PROCESSING

Maintaining fairness and timeliness is paramount to OFS . By adhering to regulatory standards and continuous procedure updates , OFS ensures accurate and compliant medical claims processing .

“ The team investigating medical claim disputes comprising Ombudsman and case managers has vast knowledge , skills and experience in handling such cases .”

Furthermore , OFS remains vigilant in compliance with regulatory standards set forth by authorities such as BNM , continuously updating its procedures to align with evolving regulations .

“ In deciding a case , we consider the policy terms and conditions , BNM Guidelines , the law ( Financial Services Act 2013 & Islamic Financial Services Act 2013 ), legal precedents and what is fair and reasonable in the circumstances of the particular case .

“ By prioritising efficiency , accuracy , and regulatory compliance , OFS maintains its commitment to fair and timely medical claims processing ,” said Marina . – The HEALTH

HOW are medical claim disputes resolved ? The Ombudsman for Financial Services ( OFS ) provided three cases explaining its approach and process .

CASE 1

A 14-year-old girl had a papule on her chin that had grown in size for six months . She underwent CO2 ablation for the papule , and the lesion was sent for a histopathology examination . The result confirmed it as a viral wart , an infectious and contagious skin lesion . However , the insurer declined to reimburse the medical expenses for her treatment .

OFS ’ findings Under their policy ’ s exclusion clause , the insurer considered the surgery cosmetic and not medically necessary . The dermatologist who treated the insured clarified that viral warts on the face are uncommon for a 14-year-old and unrelated to acne . The attending dermatologist also confirmed that CO2 ablation was not done for cosmetic purposes but for medical reasons , as it was necessary to prevent the viral wart from spreading .

Outcome The OFS case manager shared these findings with the insurer , who agreed to revise their decision and settle the claim . Had the insurer conducted a comprehensive investigation , the dispute could have been resolved without referring the case to OFS .

CASE 2

Luna passed away in August 2021 due to Advanced Right Ureteric Grade Urothelial Cell Carcinoma . The insurer rejected the death claim on the grounds that she failed to declare her medical history of diabetes mellitus in the proposal form signed in 2019 .

OFS ’ findings Luna ’ s doctor at the National Cancer Institute wrote in the medical report that she had diabetes mellitus for 15 years . However , it was not the same doctor who made the initial diagnosis . The insurer failed to provide details regarding the diagnosis date , the treating doctor ’ s name , or the medication administered , which would have confirmed whether Luna was informed and aware of her diabetes . Luna ’ s cause of death was unrelated to the condition that was not declared .

Outcome The insurer agreed with OFS findings and revised their decision to honour the claim .

CASE 3

Riya was admitted to a medical centre for a “ Large Fibroid and Right Ovarian Endometrium Cyst ”. Her insurer approved an RM45,000 medical claim but excluded the robotic-assisted laparoscopic ( Da Vinci System ) procedure of RM10,000 on the grounds that it was not medically necessary , nor were the charges reasonable and customary as stated in the policy .

OFS ’ findings An initial Guarantee Letter stated that the Robotic Assisted Procedure was not covered . Riya ’ s doctor explained to her that the insurer would not cover the robotically assisted laparoscopic surgery . Riya was willing to proceed and signed the consent form . The insurer assessed Riya ’ s bill based on the 13th Schedule of the MMA Guidelines / Schedule of Fees ( governed by the Malaysian Government under the Private Healthcare Facilities & Services Act 2013 ). The insurer approved the Laparoscopic Myomectomy procedure fee only .

Outcome The decision was in favour of the insurer on the grounds that although Riya followed her doctor ’ s advice , the Ministry of Health Malaysia clarified that it was not fully recognised as a standard medical procedure in Malaysia . Thus , it does not satisfy the definition of “ medically necessary ” policy terms and conditions . Further , Riya was willing to proceed despite being informed that the charges would not be covered .