KUALA LUMPUR, Oct 14 — A CodeBlue survey among 855 specialists in private hospitals nationwide found that almost all of them perceived health insurers as having violated their clinical autonomy.
Only 1 per cent of respondents (10 people) said health insurance issues “never” interfered with their clinical decision-making. Nearly half found insurers “very often” conducted interference, about 44 per cent “sometimes”, and some 6 per cent “rarely”.
About 99 per cent of respondents across specialties in CodeBlue’s poll also reported that their patients experienced health insurance problems over the past year.
Half of respondents said one to five patients of theirs faced insurance coverage issues every month on average over the past year, while 24 per cent had six to 10 patients a month encountering such problems.
Throughout CodeBlue’s questionnaire, more than 650 specialist doctors offered examples of health insurance companies or third-party administrators (TPAs) intruding into their practice of medicine, such as denials of coverage for various diagnostic tests, admission, procedures, and drugs or therapies for their patients.
Many anecdotes described direct payer interference with the treating physician’s treatment plans – often to the detriment of patients.
“A 7-year-old admitted with severe epigastric pain for one week, and despite giving maximal medication and morphine base medication, the request to perform endoscopy (OGDS) was denied. The reason given was the symptoms were only a week and to qualify, the child needs to have the symptoms for one month!” said a paediatric surgeon based in Kuala Lumpur or Selangor.
OGDS, or an upper GI endoscopy, is a procedure used to examine, diagnose, and treat issues in one’s upper digestive system.
A trauma and general surgeon in Penang wrote: “When they don’t allow certain procedures, hence patients are treated in a substandard way.”
Many complained that health insurers denied coverage of inpatient care, insisting on daycare or outpatient treatment instead. “Patient in pain, but asked to treat as outpatient,” said a pain management specialist practising in Sabah.
Insurers also deny coverage of patients admitted on Sundays or public holidays for surgery the next day on Mondays or weekdays.
An anaesthesiologist in KL/Selangor explained that some patients require pre-op investigation and optimisation before their operation. “As a result, patients have to be admitted after midnight and doctors have to be troubled to review them and their results in the wee hours of the morning, causing stress to all parties involved.”
Specialists highlighted insurers demanding that major procedures requiring inpatient care, like a laparotomy (open abdominal surgery) or excisional haemorrhoidectomy (surgery to remove haemorrhoids), be performed as daycare instead.
A few specialists even highlighted increased morbidity, allegedly due to insurance dictates. “We have a patient with pneumonia and hypoxia and needed a bronchoscopy, but told to treat conservatively. The patient deteriorated and needed repeated admission for partially treated pneumonia,” said a general medicine (internal medicine) specialist in KL/Selangor.
A respiratory medicine specialist in Penang said insurance denial of admission for acute bronchitis resulted in the patient developing acute bronchopneumonia, leading to high dependency unit (HDU) care and longer hospitalisation.
“Patient was denied admission for a drug given by IV infusion. So her arthritis remained very poorly controlled with significant disability,” said a rheumatologist in KL/Selangor.
On how insurers interfered with medical practitioners’ clinical decisions, an ear, nose & throat (ENT) specialist practising in the Klang Valley said simply: “Teaching us what surgery to do, when to do, what drugs to administer, and duration of treatment.”
A few respondents accused insurers of denying payment of specialist fees for procedures and consultations.
Four specialists gave positive feedback for health insurance companies, describing them as generally or mostly “okay”. A Melaka-based orthopaedic surgeon said: “Some insurers are good and consistent; depends on the management and who they employ.”
Below is a slideshow of all the charts in CodeBlue’s survey. The chart graphics can be downloaded from our Facebook post here.
Delayed Approvals, Denials Of Inpatient Care, Treatment/Procedure, Diagnostic Tests
Among 849 respondents who answered a question on their patients’ health insurance problems over the past year, 80 per cent cited delayed approvals for guarantee letters (GLs) or claims. Some 79 per cent cited denial of inpatient care or insurers only allowing outpatient care.
More than three in four respondents raised denials of treatment or procedures, while 65 per cent complained about denial of diagnostic tests (MRI, CT, blood tests).
About 48 per cent said GLs for their patients were revoked after admission over the past year. Some 42 per cent cited partial insurance coverage (large out-of-pocket required), while 31 per cent highlighted denial of innovative or branded drugs.
Among 831 respondents answering another question, 59 per cent said procedures were the treatment that patients had problems with seeking coverage.
A psychiatrist said insurance companies don’t cover psychiatry treatment, either as inpatient referrals from other specialties or outpatient, while a palliative medicine specialist complained about denial of palliative care.
Other specialists complained about insurance denials of standard surgical procedures recommended by clinical guidelines, certain implants despite approval by the Medical Device Authority (MDA), as well as newer technology like water vapour therapy for treating benign prostatic hyperplasia (BPH) and robotic surgery.
Respondents reported insurers denying coverage of various exams or tests, such as surveillance colonoscopy following colon cancer surgery or genetic testing to aid in decision-making for systemic therapy.
Yet, at the same time, insurance required investigations deemed unnecessary to clinicians. An example was “ultrasound for sebaceous cyst, CT for incarcerated hernia.” A sebaceous cyst is a fluid-filled lump under your skin, whereas an incarcerated hernia is a hernia that’s stuck. Another insurer request was a wrist MRI to diagnose carpal tunnel syndrome.
Other examples cited by several respondents included insurers requesting the lipid profile or blood sugar levels of patients admitted for various conditions like viral fever with severe dehydration, fracture, pneumonia, dengue, or food poisoning – which the clinicians considered irrelevant to their diagnosis.
Consequences Of Insurance Denials Or Delays: Delayed Treatment, Switch To Public Hospitals, Can’t Afford Treatment
Among 848 respondents who answered a question on the consequences of insurance denials or delays, 73 per cent reported that their patients delayed treatment, 73 per cent said their patients switched health care providers from private to public, while for 69 per cent of respondents, their patients couldn’t afford treatment.
Nearly four in 10 respondents reported worsening of patient outcomes, while 29 per cent said their patients switched to generic or less effective medicines.
Some 4 per cent reported that their patients were forced to either pay first and claim from insurance later, self-pay or fork out their own money out-of-pocket, or co-pay with insurance for the cost difference of treatment (i.e. “forced co-payment”).
An ophthalmologist in Pahang related how a patient requested multifocal intraocular lens implant. Their insurance policy covered only monofocal, up to RM1,000. But when asked to pay the difference, insurance only covered the exact price of a monofocal intraocular lens, instead of RM1,000, “which means the patient had to pay more extra.”
The finding that more than seven in 10 specialists in private practice had to refer their patients to government hospitals due to insurance issues sheds new light, as the public often perceives that private hospitals send referrals to public facilities due to supposed inability or refusal to handle complex cases.
“We were told to transfer a dengue patient in a cytokine storm to a government hospital,” said a general medicine (internal medicine) specialist in the Klang Valley.
A plastic and reconstructive surgeon highlighted a case of a road traffic accident, with incidental findings of high RBS (random blood sugar) or CT face/brain reported as sinusitis. When the patient was admitted for emergency surgery, the “initial” GL was revoked due to “undisclosed prior pre-existing” conditions. “Surgery deferred, delayed, and eventually transferred to MOH (Ministry of Health) facility,” he wrote.
“Patient was asked to pay and claim. They didn’t have the cash upfront, so had to be referred to government hospital in spite of the fact that they had RM500,000 coverage,” said an oncologist in Melaka.
A pain management specialist in Kedah wrote, “Many instances, unable to proceed with treatment as insurance not cleared—patient had to revert to GH (general hospital).”
Many respondents said insurance denials or delays led to patients discharging at their own risk (AOR) or defaulting on treatment.
Without elaboration, a few specialists simply said their patients died or suffered before death. Others reported their patients having poor quality of life or suffering in pain as a result of insurance denials or delays, despite paying premiums regularly.
“Patient’s condition became worse. Delayed treatment till patient died,” said a urologist based in Johor, in response to a question on how insurance denial or revocation affected patient care.
Some patients were forced to collect donations, take up loans, or sell their property to fund their treatment denied by insurance. Respondents also reported their patients resorting to traditional or alternative medicines that worsened outcomes.
“Parents were very distressed and disillusioned by the delay and eventually declined GL, and in general felt that we as the doctor in charge were not capable enough to secure the desired decision from the insurers,” wrote a paediatric surgeon in Perak.
A few respondents said they sometimes waived their fees or ended up paying for poor patients.
Many specialists lamented about bearing the brunt of patients’ anger for insurance denials or delays. “PATIENTS EVENTUALLY BLAME DOCTORS FOR POOR MANAGEMENT,” wrote a Penang-based respiratory medicine specialist in all caps.
67% Say GL Revoked After Admission/Treatment, 53% Say Coverage Denied For Various Drugs, Including Innovators
More than two-thirds of respondents at 67 per cent said they’ve experienced cases of insurers revoking or refusing to issue GLs for their patients after admission or treatment.
A few specialists said insurers cited pre-existing conditions for revoking or denying GLs, such as “anticipated” non-communicable diseases (NCDs) despite patients not having suffered medical illness previously.
A Pahang-based maxillofacial surgeon said an operation was performed based on a previously approved “initial” GL, but the “final” GL wasn’t approved and she ended up having to personally pay the supplier for implants because her patient refused to pay for the treatment.
An orthopaedic surgeon based in the Klang Valley related that after a patient was admitted at night and underwent emergency surgery, insurers then said their GL only covered daycare procedures.
About 53 per cent of respondents said health insurers or TPAs have denied coverage of various medicines and therapies for their patients, including innovator drugs. Many complained about generic-only mandates from payers.
Specialists cited multiple examples of medicines denied by insurance, such as biologics for various conditions, including inflammatory bowel disease and autoimmune diseases; targeted therapy Herceptin for breast cancer; immunotherapy for cancer; Ozempic for severe diabetes and obesity; IV painkiller Dynastat; statin for stroke; and original or high-end antibiotics, among others.
Vitamins or iron replacement therapy considered by insurance to be “supplements” were also denied.
Several specialists reported that insurance coverage was denied for semaglutide to treat Type 2 diabetes, on the basis that the GLP-1 receptor agonist was indicated for weight loss.
Claims Officers Barely Understand Diagnosis/Treatment, Insurers Ask Irrelevant Questions
About 83 per cent of respondents, most of whom are senior specialists, said insurance claims processing officers have little or no understanding whatsoever of the diagnosis or treatment being sought, especially for more complex cases.
Only one respondent said insurance claims officers had “complete” understanding. On a scale of 1 to 5 (1: does not understand at all and 5: understands completely), the weighted average of respondents’ rating of insurance claims officers’ understanding was 1.88.
Nearly three in four respondents said insurers always or usually asked doctors irrelevant questions when clarifying admission or coverage, particularly those unrelated to their patients’ problems.
Some insurers asked doctors about the causes of diabetes or hypertension. Another gem of a question: “If you don’t treat the patient, what will happen?”
A paediatrician based in KL/Selangor gave an example of insurers requesting an imaging report to prove her diagnosis of viral fever.
About 79 per cent of respondents said appeals to insurance denials were only successful sometimes (49.6 per cent) or rarely (29.6 per cent).
About 42 per cent of respondents reported facing pressure “sometimes” from insurance agents seeking coverage for patients whose policies excluded certain conditions or pre-existing illnesses. Another 20 per cent reported frequency at “usually”.
Nearly half of respondents said they or their staff spend two to five hours each week handling insurance paperwork, GL requests, or appeals.
Most Respondents Are Senior Specialists, Surgeons Most Common
Most of the 855 respondents in CodeBlue’s survey are senior specialists, with 51 per cent having over a decade’s experience and 26 per cent with five to 10 years’ experience in private practice.
CodeBlue’s poll had representation from every major specialty in the country. General and orthopaedic surgeons formed the highest number of respondents at 12 per cent and 11 per cent respectively, comprising 192 respondents.
More than half of respondents practise in the Klang Valley. Another 10 per cent are located in Penang and Johor respectively. Men outnumbered women at 74 per cent to 26 per cent.
Survey Methodology
CodeBlue conducted our online survey via SurveyMonkey from September 25 to October 5, 2025. The poll had 20 questions in total, including two open-ended questions and an optional one requesting contact information.
We used convenience sampling by directly sending the survey link to various medical associations, private hospitals, and our own specialist contacts for help to distribute among their colleagues.
The survey link wasn’t published by CodeBlue to prevent the general public from accessing the poll.
A total of 859 respondents participated in the survey; we removed four of them because two wrote that they were an admin executive or “from the business operation”, while another two declined to specify their specialty, resulting in a final sample of 855 respondents.
Our poll did not ask for respondents’ National Specialist Register (NSR) number, names, or place of work to preserve anonymity, due to doctors’ general fear of reprisal from either their hospital or insurer/TPA.
The poll was titled “Survey for Private Specialists: Health Insurance Issues Faced By Your Patients in Private Hospitals”.
Our survey title, along with the questions, were specifically designed to elicit responses on health insurance issues encountered by specialists as the treating physicians on the ground, rather than our poll acting as a neutral measure of doctors’ attitudes towards insurance.
Although health insurance premium hikes have entered public discourse, little is known about problems when policyholders actually try to claim their benefits, upon entering the health care system, that that they’d been paying for with years of premiums.
Crucially, our survey reveals the once-unknown interactions between clinicians and insurers when managing patients trying to access their insurance coverage.
Health insurance appears to be a huge issue to the medical fraternity, with overwhelming participation in CodeBlue’s poll from over 850 specialists who belong to a typically reticent profession.
Over 240 specialists, more than a quarter of respondents, voluntarily left their contact information for CodeBlue to approach for further comments.
This article is the first in a series of four articles on CodeBlue’s survey among specialists in private hospitals on health insurance problems faced by their patients. Due to the hundreds of subjective answers received in voluminous responses, the other articles will focus on specific facets of the poll.
