How To Make A Medical Insurance Claim In 4 Steps

medical insurance claim

Need to make a medical insurance claim, or just curious about how it works? Here’s what you need to know.

Why do I need to make a medical claim? Can’t I just use my medical card?

In an ideal world, we would just have to wave our medical cards to get medical attention, without having to fork out for hospital bills. Well, it does work that way…in some scenarios.

Some insurance policies are cashless policies, where you can present your medical card during admission to a panel hospital. The hospital will authenticate your details with the insurer, who will issue a Letter of Guarantee after confirming that you fulfil the policy’s terms and conditions. This letter guarantees that your insurer will cover your hospital bills, allowing you to be admitted without having to pay the hospital bills yourself.

However, this doesn’t always happen. You may need to pay your hospital bill upfront if:

  • You don’t have a cashless insurance policy. Some policies are reimbursement policies, which will require you to settle the hospital bills first before claiming for reimbursement later.
  • You were treated by a non-participating doctor or at a non-panel hospital. If your doctor or hospital is not covered by your policy, you will need to settle your hospital bills first and make a medical claim after you are discharged.
  • You were treated overseas. You may not be able to use your medical card overseas. However, depending on your policy’s terms and conditions, you may be able to claim for reimbursement.
  • Your insurer did not issue a Letter of Guarantee. If, for whatever reason, your insurer does not issue a Letter of Guarantee, you can pay upfront and make a medical claim after you are discharged.

What should you do before you get treatment?

Before you receive non-emergency treatment, contact your insurance provider or agent. That could clear up any confusion or disappointment that could arise if you try to claim for treatment that isn’t covered by your policy.

In addition, have your medical card ready so that your hospital can arrange for your Letter of Guarantee to be issued, if applicable.

How to make a medical claim

Claim procedures will vary depending on your provider, but the process generally goes like this:

Step 1. Prepare the required documents

The required documents may vary depending on your insurance provider and policy, so it’s best to check with them beforehand. You’ll typically need to prepare the following documents:

  • A photocopy of your NRIC/passport
  • Original hospital receipts and invoices
  • Itemised hospital bills/detailed bills
  • Any diagnostic reports (blood test, coronary angiogram, X-ray, etc.)
  • For overseas treatment: passport copies, boarding pass, flight ticket details, original itemised bill (and English translation, if necessary)

Step 2. Complete the required claim forms

To obtain the claim forms, contact your insurance provider or download a copy from your insurer’s website. Depending on your policy, your doctor may need to fill in a Medical Examiner’s Statement, which is a medical report that provides your insurer with more information about your diagnosis and treatment.

Step 3. Review and make copies

Check your documents to make sure that everything is in order. It’s a good idea to make copies of them before submitting your claim. You may need to refer to them if there are complications with your claim.

Step 4: Submit your claim

Submit your claim to your agent or at your insurer’s branch. Some insurance providers will also allow you to submit these online. And that’s it! Although you’ll need to be careful as you collect all the necessary documents and fill in the forms, the process is pretty straightforward.

While you wait for your claim to be approved, you can check the status of your claim by contacting your agent, calling your insurer’s customer service line, or sending an e-mail to your insurer.

If your medical insurance claim is denied, can you appeal?

Look through your policy terms again and review your submitted forms to see if everything is in order.

If you feel that your claim has been wrongly denied, you can lodge a complaint with your insurance provider’s complaint unit. And if that fails, you can seek help from PIAM Information Centre (PIC) and Ombudsman for Financial Services (OFS). Consumers who hold an insurance policy with a provider that is a member of PIAM can get help from PIC and OFS to resolve disputes related to insurance matters.

Don’t delay

We know that dealing with paperwork is a hassle, but you’ll need to submit your claim within a time limit; usually within 30 days of treatment. If you miss this window, your claim may not be approved. A successful claim could mean the difference between being able to cover your treatment costs and being saddled with medical debt, so it’s best not to delay.

This article was first published in July 2019 and has been updated for freshness, accuracy and comprehensiveness.

Read More:
How To File Your Travel Insurance Claim In Malaysia
How To Make A Car Insurance Claim

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