KUALA LUMPUR, Nov 17 — The Grievance Mechanism Committee (GMC), reactivated amid perceived interference by insurers and payers with health care providers’ clinical decisions, held its first meeting last Monday.
GMC is represented by five member organisations: the Malaysian Medical Association (MMA), the Association of Private Hospitals Malaysia (APHM), the Life Insurance Association of Malaysia (LIAM), General Insurance Association of Malaysia (PIAM), and the Malaysian Takaful Association (MTA).
Officials from the Ministry of Health (MOH) and Bank Negara Malaysia (BNM) joined the November 10 meeting as observers.
“During the meeting, the GMC committed to improving communications among all members and agreed to cooperate on developing transparent claims protocols for the management of claims that are payable under medical and health insurance/takaful products,” said GMC in a statement issued by MMA, APHM, LIAM, MTA, and PIAM last Saturday.
“The claims protocols will be co-developed by specialists and payers and are intended to provide clearer guidance to medical practitioners, ITOs (insurers and takaful operators) and hospitals on treatment costs that can be claimed under medical insurance and takaful policies. This in turn aims to reduce delays in the claims process and minimise disputes.”
GMC said while it does not adjudicate individual disputes or impose punitive action, it reviews complaints received through medical professional bodies and industry associations, “with the objective of resolving differences by bridging knowledge gaps between the medical and insurance sectors and providing broad guidance consistent with the fair treatment of policyholders and ethical management of patients”.
GMC said it would immediately prioritise claims protocols to deal with “common claims pain points”, without specifying what these were.
“We welcome the revival of the GMC and value the open, constructive dialogue it fosters between the medical profession and the insurance sector. This collaboration is crucial in ensuring that patient welfare remains the top priority while improving mutual understanding and trust across the health care ecosystem,” MMA president Dr R. Arasu was quoted as saying in GMC’s statement.
LIAM chief executive officer Mark O’Dell, speaking on behalf of the ITO industry, said the insurance industry’s focus was on protecting policyholders, improving claims clarity, and ensuring access to fair, efficient, and timely medical coverage.
“By working closely with doctors, hospitals and regulators, we can foster greater trust between the industry and the medical community, while safeguarding the interests of our policyholders and participants, and delivering on our promise of timely protection and commitment to fairness and mutual assistance.”
APHM president Dr Kuljit Singh said GMC provides an important platform for private hospitals and insurers to work together in a spirit of partnership and transparency.
“By aligning practices and addressing issues collectively, we can enhance efficiency, strengthen trust, and ultimately deliver better outcomes for patients.”
CodeBlue recently reported BNM’s request to all ITOs and third-party administrators (TPAs) to explain their alleged interference with clinical decision-making, including delays, denials, and revocation of guarantee letters (GLs) after admission or treatment.
In a nationwide CodeBlue poll of over 850 private specialists, respondents reported ITOs and TPAs denying inpatient admissions by reclassifying cases as daycare or outpatient treatment. Specialists also reported rejection of general anaesthesia for surgical procedures and refusal to cover standard therapies, including both innovator and generic medicines.
Doctors did not claim that payers directly issued clinical instructions. Instead, they described the control of GLs, claim approvals, and payment authorisations as a form of financial gatekeeping that influenced clinical judgement in practice.
