KUALA LUMPUR, Dec 4 — Insurance agents in Malaysia simply act as intermediaries between insurers and policyholders, as they do not have a formal role in medical claims processes, according to the Life Insurance Association of Malaysia (LIAM).
LIAM chief executive Mark O’Dell said agents – generally viewed as the first port of call when medical claims go awry – primarily serve as go-betweens, even though many try to assist policyholders or relay decisions on their behalf.
“They have no formal role in the claims process, although they often attempt to help the customer through the claims process and often convey insurers’ decisions,” O’Dell told CodeBlue when contacted yesterday.
Case management, he added, is handled internally and overseen by a “designated officer” in an insurance company.
LIAM’s clarification highlights a mismatch between how the public perceives agents’ responsibilities and the industry’s internal structure. Policyholders often assume the person who sold them a policy – and who receives recurring commissions – will also assist them when they fall seriously ill and when insurers review hospitalisation or treatment claims.
Access to claims department staff, however, is at the discretion of individual insurers. O’Dell said, “It’s not an unreasonable request, but [it] remains the decision of the insurer whether to meet the claimant.”
Claimants generally have limited visibility into who handles their files. Most insurance companies do not publish staff directories or provide direct contacts for claims personnel. O’Dell did not specify how policyholders should identify or reach these officers.
On how much policyholders are expected to manage the claims process themselves, O’Dell said agents and insurers “are there to assist” and that rejected claims can be brought to the Financial Markets Ombudsman Services (FMOS), formerly the Ombudsman for Financial Services.
He said FMOS provides an “independent, fair and free dispute resolution” process for unresolved complaints.
The ombudsman, however, intervenes only after a claim is formally denied – not when it is stuck “under review” or when insurers repeatedly request for additional documents, circumstances that have been reported by both doctors and patients.
CodeBlue yesterday reported on the case of Ramu Krishnan Sinnamuthry, a 57-year-old stage four tongue cancer patient whose insurer, Allianz Life Insurance Malaysia Berhad, has yet to approve any of his claims, over four months after a CT scan last July.
Three cancer claims, amounting to nearly RM26,000, remain delayed due to Allianz’s “investigation” into a 2024 hypertension episode that he didn’t claim for at the time. Instead, Ramu was asked to provide medical records dating back to 2017. He has spent about RM69,000 out of pocket on diagnostic tests and treatment for cancer.
LIAM’s assertion that agents play “no formal role” in the claims process for health insurance occurs even though insurance agents are named in policy contracts, together with their identity card number and agent code.
If insurance agents’ relationship with their customers legally ends after the sale of a policy – like real estate agents selling a property, for example – it also begs the question as to why agents do additional work during the claims process, like retrieve documents or answer policyholders’ questions late at night, such as Ramu’s agent.
