Malaysia will soon reactivate the Health Grievance Mechanism Committee to address disputes involving medical claims and streamline operational practices within the insurance industry.
The reactivation exercise will happen in collaboration with Bank Negara Malaysia (BNM) and other stakeholders from the medical, hospital and insurance sectors.
Malaysia’s deputy finance minister Lim Hui Ying told the Parliament that the reactivated committee will serve as a platform to resolve issues such as delays in issuing guarantee letters and disagreements over treatments covered under insurance policies.
Ms Lim informed this to the parliament during an oral question-and-answer session earlier this month. She said the move comes amid growing concerns that insurers, takaful operators (ITOs) and third-party administrators (TPAs) have been interfering excessively in clinical decisions.
The Malaysian Medical Association (MMA) has also reportedly raised concerns over a circular issued by a TPA instructing healthcare providers on the choice of anaesthesia and the classification of certain procedures as either day care or inpatient cases.
Ms Lim said the ITOs and TPAs have no authority to determine patient care, as their role is limited to verifying whether a claimed treatment falls within policy coverage based on medical necessity and standard treatment protocols.
She said that decisions regarding patient care remain solely with doctors, and if a recommended treatment is not covered under an insurance policy, payment may be made directly by the patient.
On BNM’s interim measures to ease the impact of rising medical insurance premiums, Ms Lim said data shows that over 90% of policyholders experienced premium adjustments below 10% in the first year.
Meanwhile, BNM has received 190 complaints from policyholders regarding medical and health insurance or takaful (MHIT) premium adjustments, of which 94% or 179 cases have been resolved by ITOs.
Ms Lim emphasised that under the interim framework, ITOs must submit all relevant information to BNM for review, and any premium adjustments that do not fully comply with the measures will not be approved.