KUALA LUMPUR, Nov 6 — The Ministry of Finance (MOF) today reiterated in Parliament that insurers, takaful operators (ITOs), and third-party administrators (TPAs) cannot determine patient care, amid ongoing complaints of insurer interference in clinical decisions.
Deputy Finance Minister Lim Hui Ying told the Dewan Rakyat that ITOs and TPAs are only responsible for verifying whether a claimed treatment falls within policy coverage, based on medical necessity and standard treatment protocols. She said decisions on patient care remain solely with doctors.
“Insurers and takaful operators, as well as TPAs, have no power to determine patient care. This remains the exclusive responsibility of doctors,” Lim said in response to a question by Bayan Baru MP Sim Tze Tzin. “If the recommended treatment is not covered under the insurance policy, payment can be settled directly by the patient.”
Sim had asked how many insurers were found to have violated Bank Negara Malaysia’s (BNM) interim measures on medical and health insurance (MHIT) premium adjustments, the types of non-compliance involved, and the enforcement taken.
He also referred to findings from CodeBlue’s survey of more than 850 specialists, including reports of interference in clinical decisions, revocation of guarantee letters (GLs), denial of claims for not following treatment protocols, steep premium increases linked to age-band movement, and reductions in benefit periods.
MOF’s response mirrored BNM’s position that payers only assess whether treatment is covered and do not influence clinical decisions. However, CodeBlue’s survey responses show that specialists consistently describe insurer and TPA approval controls as affecting how care is provided in private hospitals.
Specialists reported insurers denying inpatient admission by reclassifying cases as outpatient or daycare treatment. They also reported rejection of general anaesthesia for surgical procedures and refusal to cover standard therapies, including both innovator and generic medicines.
Doctors said these decisions limit the treatment options they can offer patients.
Doctors did not claim that insurers directly issue clinical instructions. Instead, they described the control of guarantee letters, claim approvals, and payment authorisations as a form of financial gatekeeping that influences clinical judgement in practice.
CodeBlue reported yesterday that a MediExpress (Malaysia) Sdn Bhd guarantee letter limited coverage for hospitalised patients to one specialist review per day. No exemptions from this limit were specified.
Additional specialist visits on the same day would require out-of-pocket payment by the patient. Specialists’ consultation fees are capped at RM235 under Schedule 13 of the Private Healthcare Facilities and Services Act 1998 (Act 586).
The Ministry of Health (MOH) has previously cautioned insurers and TPAs against influencing clinical decision-making.
Health director-general Dr Mahathar Abd Wahab warned that interference with doctors’ clinical discretion “may be illegal” under Sections 82 and 83 of the Private Healthcare Facilities and Services Act, which protect clinical autonomy.
Medical associations have also called for regulatory intervention on insurer practices affecting care.
Over 90% Of Policyholders Saw Premium Hikes Below 10% In First Year, Says MOF
Lim said the interim measures require ITOs to submit all proposed premium adjustments to BNM for approval, and that adjustments which do not meet the interim requirements cannot be implemented.
The interim policy aimed for at least 80 per cent of policyholders to face annual premium adjustments of no more than 10 per cent due to medical inflation.
However, Lim said current industry data shows that more than 90 per cent of policyholders experienced premium adjustments of less than 10 per cent in the first year.
The DAP lawmaker said a smaller group of policyholders experienced larger increases because their policies had not been repriced for a long period. Lim added that insurers have offered these policyholders lower-cost alternative plans and that increases due to age-band movement were disclosed when policies were purchased.
Meanwhile, BNM has received 190 complaints from policyholders regarding MHIT premium adjustments, of which 94 per cent (179 complaints) have been resolved by ITOs, Lim said.
Policyholders should first bring disputes to their insurer, and unresolved matters may be escalated to BNMLINK for case-by-case review.
Lim added that the government, BNM, insurers, TPAs, hospitals and medical professionals have reactivated the Grievance Mechanism Committee (GMC) to coordinate operational issues.
GMC will serve as a platform to address delays in guarantee letters and review cases where there are disputes about whether treatment should be covered under MHIT policies. Lim said GMC may issue guidance for similar cases in the future.
