My Medical Card Claim Was Rejected – What Can I Do?
You pay your premiums every year and trust your medical card to protect you when you need it most. So when a claim gets rejected, it can feel frustrating and unfair especially if you’re facing a big hospital bill. But don’t panic just yet. Understanding why claims are rejected and knowing what to do next can help you resolve the issue, or at least avoid the same problem in future.
Common Reasons Why Medical Card Claims Get Rejected
Insurance companies don’t reject claims without reason. Some of the most common causes include:
1. Exclusions in Your Policy
Every medical card has a list of conditions and treatments that aren’t covered. For example, certain pre-existing illnesses, cosmetic surgery, or elective procedures may not be claimable. If your treatment falls under an exclusion, the insurer is likely to reject it.
2. Waiting Periods Not Over
Many policies have waiting periods for certain illnesses for example, cancer or specific surgeries may not be claimable within the first 120 days or even a year of your coverage. If you claim during this time, it’s often rejected.
3. Incomplete or Incorrect Documentation
Missing medical reports, incomplete claim forms, or errors in your paperwork can cause delays or rejection. Always check that all documents are filled out properly and that you provide clear, complete medical evidence.
4. Non-Panel Hospital or Unauthorised Treatment
If you receive treatment at a non-panel hospital or don’t get the insurer’s Guarantee Letter (GL) beforehand, you may have to pay upfront and submit a reimbursement claim. Even then, claims can be rejected if they don’t follow your policy’s terms.
5. Exceeding Your Limits
Your claim might be rejected if you exceed your annual or lifetime limit. For example, if your annual limit is RM100,000 and you’ve already claimed RM95,000, a big surgery may push you past the cap.
Steps to Take if Your Claim Was Rejected
A rejected claim isn’t always final. Here’s what you can do to clarify or appeal:
1. Review the Rejection Letter Carefully
Your insurer must provide a clear reason for rejecting your claim. Read the letter in detail and compare it with your policy terms. Check whether the rejection makes sense.
2. Contact Your Insurance Agent or Company
Speak to your agent or the insurance company’s claims department. Sometimes, a simple clarification or extra document is all that’s needed to reverse a rejection.
3. Gather Supporting Evidence
If you believe the treatment should be covered, collect additional supporting documents. This could include medical reports, referral letters, or proof that the treatment was medically necessary.
4. File a Formal Appeal
Most insurers allow you to file an appeal. Write a clear, polite letter explaining why you believe the claim should be reconsidered. Include all relevant documents and references to your policy wording.
5. Escalate to Bank Negara Malaysia (BNM)
If your appeal is denied and you still believe you’ve been treated unfairly, you can bring the matter to Bank Negara Malaysia’s Financial Consumer Alert or approach the Ombudsman for Financial Services (OFS). They may review your case and mediate a resolution.
How to Avoid Claim Rejections in the Future
- Understand your medical card’s terms, conditions, and exclusions.
- Keep track of your annual and lifetime limits.
- Always get a Guarantee Letter (GL) before admission whenever possible.
- Keep copies of all medical documents and hospital bills.
- Stay in touch with your insurance agent for any policy updates or renewals.
Final Thoughts
A rejected claim can be stressful, but it doesn’t always mean you’re out of options. By knowing your rights, understanding your policy, and following the proper steps, you can resolve misunderstandings and make the most of your medical card when you need it.
If you’re unsure about what’s covered or how to strengthen future claims, take time to review your plan and get advice from a trusted insurance advisor. The right information today can help you avoid unpleasant surprises tomorrow.
