KUALA LUMPUR, Nov 5 — In a blanket dictate, a third-party administrator (TPA) has limited coverage of specialist reviews of patients to just one a day for hospital admissions.
According to a November 1 guarantee letter (GL) from MediExpress (Malaysia) Sdn Bhd, sighted by CodeBlue, the company will only cover a “maximum of one physician visit per day for surgical/non-surgical admission”. No exemptions from this limit were specified.
This effectively means that any additional doctor visits in a single day will have to be paid out of pocket by the insured patient. Specialists’ consultation fees are capped at RM235 under Schedule 13 of the Private Healthcare Facilities and Services Act 1998 (Act 586).
“The very notion that a patient requires only one medical review per day is fundamentally flawed,” a paediatrician from Penang, who requested anonymity, told CodeBlue when commenting on MediExpress’ GL.
“Medicine does not follow clockwork precision. A patient who appears stable in the morning may deteriorate by evening, requiring urgent reassessment, treatment adjustment, or even escalation of care. This policy fails to recognise the dynamic nature of illness and recovery.”
He added that he personally knew of at least two cases subject to the same MediExpress limit on daily doctor reviews.
The Penang specialist doctor said the restriction is especially concerning for postoperative and intensive care settings, where continuous monitoring and timely reassessments are critical.
He described the policy as “financial gatekeeping rather than facilitation of health care”, accusing MediExpress of undermining both patient welfare and doctors’ professional autonomy.
“By prioritising cost-cutting over clinical judgment, MediExpress undermines not only patient welfare but also the professional autonomy of doctors,” the doctor said. “Such policies erode trust, distort standards of care, and turn medical decisions into financial calculations.”
The paediatrician also highlighted the ethical concern of shifting the financial burden onto patients at their most vulnerable. “It forces a cruel trade-off between medical necessity and financial affordability – a situation that no patient should ever face under an insurance system that purports to protect their health.”
MediExpress’ GL further limits admission duration to five days and requires “top-up” approval for extended stays or coverage exceeding RM10,000.
It contains additional conditions, including restrictions on cross-referrals, exclusions for certain items and procedures, and a clause allowing the TPA to retract the GL if the final diagnosis differs from the provisional one.
The GL also lists numerous exclusions, including certain external appliances, supplements, and procedures deemed not “medically necessary to be hospitalised”, while requiring hospitals to obtain prior approval for cross-referrals and additional treatments.
Such guarantee letters are typically issued by insurers or TPAs to hospitals as proof of coverage for policyholders’ medical expenses. While CodeBlue cannot verify whether the clause limiting doctor visits applies to all GLs issued by MediExpress, the document indicates a policy that caps the number of reimbursable doctor reviews per day.
The paediatrician who spoke to CodeBlue said such limits contradict standard clinical practice, where the frequency of patient reviews should be determined by medical need rather than administrative rules.
“Health care systems exist to support the doctor-patient relationship, not to police or penalise it,” the paediatrician said. “If MediExpress continues on this trajectory, it risks losing credibility as a partner in health care – and becoming instead a barrier to it.”
CodeBlue has contacted MediExpress for comment.
MediExpress’ new restriction comes amid growing scrutiny of insurer and TPA interference in doctors’ clinical decisions. Last month, CodeBlue’s nationwide survey of 855 private specialists found that 99 per cent had experienced some form of interference, including delayed guarantee letters, restrictions on anaesthesia use, or denials of standard treatments.
Health director-general Dr Mahathar Abd Wahab recently issued a public warning that insurance companies and TPAs had no legal authority to overrule clinical decisions, citing possible contraventions of Act 586.
He also warned payers against conditioning GL approvals or setting reimbursement on “predetermined clinical choices”.
The Ministry of Health (MOH) has since said it had been tasked by the Cabinet on June 25 to study regulatory options for TPAs and managed care organisations (MCOs).
Under the current framework, Bank Negara Malaysia (BNM) regulates insurers and takaful operators (ITOs), while the MOH oversees TPAs registered as MCOs. Both authorities have separately affirmed that administrative intermediaries are not authorised to direct patient care.
