KUALA LUMPUR, Oct 17 — Private specialist doctors say health insurers are increasingly second-guessing their clinical decisions through approval processes dominated by redundant and irrelevant questions often made not by doctors, but by administrative staff.
Responses from CodeBlue’s nationwide survey of 855 specialists across specialties show that health insurance/takaful companies and third-party administrators (TPAs) frequently require doctors to respond to lengthy, repetitive, or illogical queries before issuing guarantee letters (GLs), even for straightforward or urgent cases.
Specialists said the people behind these queries – typically processing officers or clerical staff – often lack medical training. Yet their decisions determine whether a patient receives or is denied or delayed care.
Administrative Interrogations Masquerading As ‘Clinical Review’
Doctors said insurers often issue multiple rounds of questions, sometimes repeating the same ones, on matters already covered in initial admission notes.
An orthopaedic surgeon in Melaka said insurers kept issuing “repeated queries on procedures done even though it was all written on the pre-admission forms.”
A general surgeon in Pahang echoed the same frustration: “Repeated questions about hospitalisation applications, often asking the same questions over and over again.”
Another urologist in the Klang Valley described “unnecessary delay in approval by asking frivolous secondary questions”, adding that insurers sometimes “try to advise the doctors what is the best option of treatment”.
Several specialists said they have had to explain basic medical procedures to insurance staff who “appear to have little or no medical background” or are “medically untrained”.
“Case reviewed by inexperienced insurance staff,” wrote an internal medicine specialist in Kuala Lumpur/Selangor.
A gastroenterology and hepatology specialist in the Klang Valley said: “Staff vetting admissions are poorly trained and don’t know basic medical terms. Pathetic.”
A nuclear medicine specialist in Penang commented: “People vetting the coverage have no knowledge of what they are asking.”
A paediatric surgeon in Perak noted that the queries themselves sometimes revealed who was behind them: “Grammatically incorrect queries, which seem to indicate that consultant specialist responses are being replied to by clerical staff.”
Doctors said the problem lies not just in bureaucracy, but in the fact that decisions about patient care are being made by non-medical personnel following checklists instead of clinical judgment.
A neurosurgeon in the Klang Valley wrote: “Constant harassment – endless questions which have already been covered in the GL application.”
Another orthopaedic surgeon in Melaka said the same insurer repeatedly asked identical questions, even after he had answered them several times. “When I told them this was the last time I am replying, they removed me from their panel. Harassment is a common tactic,” he said.
An ophthalmologist in Johor noted that insurers’ so-called quality assurance (QA) demands have also become excessive, consuming valuable clinical time and diverting focus from patient care.
“The administrative burden and cost of handling QA far exceed the procedure fees and are not reimbursable,” he said. “QA questions are often vague, poorly constructed, and lack two-way communication. Requests for clarification are routinely ignored.”
Irrelevant Or Illogical Questions That Delay Urgent Care
Many specialists said insurers often demand answers to irrelevant or illogical medical questions, or ask for test results that can only be obtained after treatment begins.
A general surgeon in KL/Selangor recounted being asked whether “a 74-year-old lady was pregnant,” a question that delayed approval for her admission. An ENT specialist in Perak reported a similar experience, saying the insurer queried, “Is the patient pregnant?” – even though the patient was a man.
In Melaka, a cardiologist said he was asked why a coronary angiogram “cannot be done as an outpatient procedure”.
Other respondents said they were instructed to submit tumour pathology reports before surgery or to justify the use of anaesthesia for procedures known to be painful.
One internal medicine specialist in Kedah described being told to conduct unnecessary tests before approval: “Requested for ridiculous tests pre-GL approval. Example: admitting for viral fever with severe dehydration. Insurance company requested a lipid profile and blood sugar, which are irrelevant to the diagnosis.”
An ENT specialist in the Klang Valley wrote: “Admission for sinusitis or epistaxis needing CT scan report prior to GL approval.”
A paediatrician in the Klang Valley said insurers also request duplicate investigations: “They asked to unnecessarily repeat tests when it is already well documented influenza positive from the referring GP, but still want the hospital to repeat. Another example is asking for a CXR even though clinically already diagnosed pneumonia.”
A haematologist in KL/Selangor said even approved claims can later be revoked over technicalities. “Patient done GL approved for 1st R-CHOP chemo as inpatient, but merely because he was discharged on the same day, but exceeded 6-8 hours. Insurance revoked the GL, claiming that the patient’s policy doesn’t allow same-day discharge. So, insurance is forcing doctors to keep an extra night, and waste more money,” she said.
“So it isn’t true that we doctors or hospitals are causing the medical cost to rise. It is unfair assessors simply making unreasonable excuses, and as a result, patients stay longer, hospital bills increase. Therefore, insurance pool funds are depleted unnecessarily and rakyat suffer from rising premiums.”
Non-Medical Staff Overriding Doctors
Specialists said insurance approvals are often handled by administrative officers with no medical expertise, resulting in questionable decisions that override doctors’ clinical judgment.
Several respondents said insurers now dictate clinical details from whether patients should receive intravenous (IV) drips to the type of anaesthesia used or the amount of medication that falls under coverage.
A general surgeon in Melaka said insurers rely on rigid definitions that ignore real-world clinical variation. “Insurance companies have their own definitions of diseases and treatments required, very much based on the books rather than clinical situations, which are never the same for every patient,” he wrote.
“Also, for a patient to be justified to be staying as inpatient, the patient must be having IV medication, otherwise cannot be staying in, which is ludicrous because patients may be still having abdominal drains/urinary catheter requiring close monitoring after surgery and not safe for early discharge, that would justify ongoing hospital stays. But insurance companies would refuse to accept this.”
A KL/Selangor anaesthesiologist said insurers show a limited understanding of how treatment works. “Insurance implies that treatment is only drugs in IV form, surgery. Post-discharge consults and procedures are often not covered. They have the opinion that sedation is less risky than general anesthesia, and demand that the charges be less. They do not cover procedures like regional anesthesia, thinking it is without extra risk or cost.”
A paediatrician in Perak said reviewers often make decisions without any medical training. “Insurance companies cannot decide what treatment should be given in patients and determine which patients can be admitted, despite giving reasons for admission and clinical data as the reviewers are all medically untrained.
“Unnecessary IV drips and IV treatment in children to qualify for admission, despite their clinical condition requiring close observation and oral treatment,” she said.
The same paediatrician noted how strict cut-offs can also endanger newborns. “Coverage for neonatal jaundice in most insurance dictates bilirubin level of 15mg/dL, irrespective of days of life or risk factors, so hard to claim if the result of a two-day-old baby is 13 mg/dL.”
A cardiologist in the Klang Valley said these arbitrary rules have knock-on effects across the system. “Health insurance companies are contributing to the increasing cost of health care indirectly, such as, by mandating certain intravenous medication/drips as first line or mandatory treatment to justify admission/GL approval.”
He added that doctors “should not be mandated” to initiate treatment mandated by insurance companies, such as IV drips if clinically not indicated, and called for insurers to follow standardised, regularly updated clinical practice guidelines.
An ophthalmologist in Johor described a case where an insurer rejected a claim after disregarding three separate specialist assessments. “Insurance reviewers appear to override clinical judgement, making diagnostic decisions without basis. Despite two specialist referrals and my own assessment ruling out congenital causes, the claim was denied for being congenital – with no explanation provided when queried.”
An anaesthesiologist in the Klang Valley described being asked to justify using sedation for cardioversion – a procedure that delivers an electric shock to the heart to correct an abnormal rhythm. “Simple common sense dictates that no one will enjoy 100J of energy passing through their body,” he wrote.
A System Where Clerks Second-Guess Clinicians
Specialists across medical fields said the growing volume of irrelevant queries reflects a deeper shift in decision-making power away from clinicians and toward administrative officers with little or no medical training.
A respiratory medicine specialist in the Klang Valley described how approvals are sometimes denied simply because test results appear normal: “Patient don’t require certain tests like CT or don’t require admission despite severe symptoms. Denial sometimes based on no abnormal test results rather than doctor’s justification.”
A pain management specialist in Kedah said such bureaucratic practices harm both patients and practitioners. “Patients are being cheated of treatment that is necessary, doctors being stressed with repetitive paperwork, and time could be spent better treating patients adds to overall stress of practitioners,” she said.
The findings suggest that irrelevant queries are part of a broader pattern of administrative obstruction, echoing earlier survey findings that insurers “delay, deny, or revoke” coverage of patient care, and restrict access to medicines by labelling them “non-medical” or “not indicated”.
This story is the fourth and final article in CodeBlue’s series on health insurance practices in Malaysia, based on a nationwide survey among 855 specialists practising in private hospitals.
Read the first three articles here:
