KUALA LUMPUR, Dec 1

A senior oncologist has recommended that patients consider asking their lawyers to communicate with insurance companies regarding denied medical claims, without necessarily resorting to litigation.

Dr. Mohamed Ibrahim A. Wahid, an experienced clinical oncologist, noted he has suggested to some of his patients that they seek legal advice when faced with denial of insurance coverage due to what he perceives as ambiguous policy interpretations.

“In some cases, a lawyer simply needs to send a letter to the insurer asking, ‘Why was this claim denied? What are your justifications? Where in your policy does it state that this fee isn’t covered?'”

“Things are really turned upside down.”

Dr. Ibrahim also highlighted that if an insurance company opts to challenge a claim denial in court, it may struggle to find medical experts willing to testify as advocates for the insurance side.

“I don’t believe many professionals will support them. They’ll prioritize their own integrity and the welfare of patients over pleasing the insurance companies,” he commented.

He encouraged the public to converse with lawyers over claim rejections, as legal experts can better decode insurance policies to help determine if a denial can be contested.

“When obstacles emerge, most professionals—including oncologists—will tend to protect themselves and advocate for their patients.”

Raja Irene Soraya Raja Aman, a managing partner at a law firm, mentioned that patients might take legal action against insurance firms, takaful operators, or third-party administrators for claim denials or delays.

RM1 million insurance, RM130 monthly oral cancer treatment denied

In another point, the podcaster Khoo highlighted that many individuals take out medical plans with lofty coverage limits—like RM1 million—optimistically assuming they will be protected in emergencies.

“Yet, when a medical crisis strikes and they seek hospital care, they often find themselves facing coverage denial,” Khoo remarked.

Dr. Ibrahim agreed. “With insurance claims, there are often hidden clauses in the fine print that can go unnoticed—those can impact the RM1 million coverage.” He elaborated that this can influence how much one can claim and what will actually be reimbursed.

He emphasized that some treatments, such as hormone therapy for breast cancer, which can last up to a decade, are typically not covered despite being essential for ongoing health.

“It’s similar to managing diabetes,” Dr. Ibrahim illustrated. “If you stop your medication, blood sugar will spike, much like how discontinuing cancer treatment can lead to relapse.”

He recounted a scenario where a patient faced denial for a modest RM130 claim despite holding a RM1 million policy, leaving patients little choice but to rely on government facilities due to financial constraints.

“The financial burden shifts from the insurance provider, who was meant to cover that cost, to the health department,” he stated. “The Ministry of Health is already overwhelmed—why should they be taking on insurance company responsibilities?”

Khoo mentioned observations that a majority of claim denials are issued by “major companies” which represent a significant portion of the industry.

In a more personal reflection, he recounted having raised his own medical coverage to over RM1 million earlier this year, seeking reassurance, though he found that sense of security to be illusory.

Patients were allegedly given a 50% refund after the court decided to dismiss the unfair charges.

Dr. Ibrahim and Khoo also touched on regulatory uncertainties in health insurance. Khoo pointed out that Bank Negara Malaysia acts as a financial regulator, overseeing banks and insurers but lacking medical expertise.

“So for patients experiencing issues, where do they turn?” he asked.

Dr. Ibrahim shared that the central bank lacks detailed insight into healthcare, and the Ministry of Health doesn’t oversee third-party operators.

“There’s a significant governance gap in Malaysia, allowing insurers to exploit these gray areas to create their own rules.”

In a recent statement, Health Director-General Dr. Mahatar Abd Wahab cautioned that interference with clinical decisions by insurers could breach healthcare regulations.

“If you deny necessary treatments, you’re violating laws,” Dr. Ibrahim remarked, noting that despite such warnings, little has changed.

Referring to public statements from insurance providers, he highlighted that many are accruing substantial profits.

“I’ve spoken to countless insurers and they are raking in hundreds of millions—if not billions—of ringgit,” the financial journalist noted.

Bank Negara recently reactivated its Grievance Mechanism Committee to mediate disputes between healthcare providers and insurers, while the Financial Markets Ombudsman Service also addresses financial disputes, including those related to insurance.

Nonetheless, Dr. Ibrahim pointed out that even if a claim is deemed unjustly denied, the penalty for insurers often amounts to little more than a mild reprimand. Some patients, he indicated, had even received merely half of their expected reimbursements.

“I would suggest sanctions that significantly impact these insurers. If fines were more substantial, perhaps they would reconsider their practices,” he remarked.

Malaysia has the lowest medical costs in Southeast Asia

Despite the rising costs of private healthcare, Dr. Ibrahim noted that Malaysia still ranks among the most affordable options in Southeast Asia, an observation supported by the country’s active medical tourism sector.

“Our prices are considerably lower than in neighboring nations,” he stated.

“For instance, a PET scan may cost between RM5,000 and RM6,000 in Indonesia, while in Malaysia, it’s around RM2,300.”

Reflecting on his time in the UK and the US, Dr. Ibrahim asserted that Malaysia offers one of the best healthcare systems globally.

Quality of care and medical facilities in Malaysia often match or exceed those found in other countries.

“We shouldn’t risk damaging the medical industry due to unfounded accusations that private hospitals overcharge,” he warned, noting that rising healthcare costs are paralleled by increases in the costs of goods and services.

He reiterated the pressing issue of insurance companies denying valid health claims, despite promises of substantial coverage.

“When actual bills arise, you find many are ineligible for reimbursement,” he concluded.