A young toddler arrives at the clinic exhibiting high fever, cough, mouth ulcers, and significant dehydration, necessitating hospital admission for intravenous fluids and antibiotics.
The child’s medical insurance was unexpectedly denied without any delay or justification, despite comprehensive documentation of the medical necessity for admission.
A considerable amount of time was then spent by the attending doctor to prepare an appeal letter, emphasising that discharging the patient would be medically unsafe. After several additional hours of delay, the insurance approval was finally granted.
This patient was one of the lucky ones as his appeal was accepted. Many are not as lucky. Such important decisions should be entirely based on clinical judgement rather than the judgment of a non-medically trained person sitting behind a computer screen in an air-conditioned insurance company office, or worse, at home.
This interference with medical decision goes against the very principles that govern medical care. Medical insurance should not override clinical care and delay decisions, or else denial of medical insurance may lead to worsening outcomes.
Unfortunately, this incident is not isolated or unique.
The recent survey published by CodeBlue involving 855 doctors have shown that almost all (99 per cent) of doctors have had issues with health care insurance providers. 79 per cent of the doctors reported having admissions being delayed or denied by insurers for a variety of medical conditions including dengue, influenza, pneumonia, and diarrhoea and vomiting illnesses.
Most admissions amongst children are under the age of 5 years old or in primary education who require prompt medical care and treatment.
Young children are more vulnerable to various infections due to their relatively immature immune systems. They have a higher tendency to have breathing difficulties due to their smaller airways and weaker respiratory muscles.
Furthermore, their circulating blood volume is lower, making them more likely to suffer from dehydration.
It takes years of training and experience for a paediatrician to be able to determine the best care for a sick child, and for that decision to be cancelled by someone who has not even seen the patient is completely unacceptable.
We welcome the recent statement from Health Director-General Dr Mahathar Abdul Wahab that reminds medical insurance providers that they are bound by Sections 82 and 83 of the Private Healthcare Facilities and Services Act 1998 (Act 586) that set out clear principles and statutory safeguards to protect clinical decision-making from undue influence.
The DG declared that “decisions regarding anaesthesia, treatment modality, and admission status must remain grounded in clinical need and ethical standards, not administrative directives or financial gatekeeping.”
He further stated any arrangement that interfered with a practitioner’s authority over patient management, or pressured them to act contrary to professional ethics, was “not only unacceptable, but it may also constitute as inconsistent with legal provisions.”
Insurers should be made aware that there may be medico legal implications and ethical concerns to be addressed especially if the delay or denial of treatment results in direct or indirect harm to patients.
The Malaysian Paediatric Association stands in unity with the entire medical community to ensure that Insurance providers work together with patients and their doctors within an established ethical framework rather than to deny, delay or revoke medical treatment for the benefit of patients of all ages.
This statement was issued by Dr Salehuddin Samsudin, Prof Dr Zulkifli Ismail, and Assoc Prof Dr Intan Juliana Abd Hamid from the Malaysian Paediatric Association (MPA).
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
