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Malaysia Medical Coverage: Initial medical card was approved but at the end its was declined. What should I do?

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asked on Sep 13, 2019 at 17:39
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edited on Dec 16, 2019 at 00:34
 
I took a medical card for my son 8 years ago and it is still active. This medical is for accident coverage.

Last month, my son had an injuries on his knee while playing football in school and his knee was swollen and painful. I brought him to one of specialist hospital in Penang and admitted him thru emergency ward by using medical card.

At the first stage, the insurance was approved and the specialist did x-ray but they couldn't diagnose it and requested for future check up by doing MRI and this was also approved by the insurance company.

The found that my son had meniscus tear and need to do operation and this was also approved by the insurance company. The operation was successfully done and the doctor informed me that my son had Discoid Menicus and the tear happened at that particular place.

He was discharged from the hospital after being admitted for 5 days.

2 weeks after he was discharged from the hospital, the specialist hospital informed me that my claim under medial card was declined and I have to bare the cost. I asked for the reason and they said that he had a congenital problem. I really could not understand this term.

I had called the insurance company and asked for the reason and they mentioned that my son had congenital issue and it was not the accident, which caused the meniscus tear. 

I highlighted this issue to the doctor who did the report and he resubmitted the report with details but still the insurance company didn't want to accept the report and they kept saying that it was due to congenital problem.

Now I had to bare the cost. I really don't have such money and I am really confused.

What should I do now? Can anyone please advise me on this matter?
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5 Answers

answered on Sep 15, 2019 at 23:29
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edited Dec 16, 2019 at 14:52
 
I asked for the reason and they said that he had a congenital problem. I really could not understand this term.

What this means is that the insurance company is saying that the your son was born with the problem in his knee. As you may know, insurance policies normally do not cover pre-existing problems or congenital problems.

If you are not satisfied, you can ask your doctor another doctor whether the problem in your son's knee was congenital. If you are still not satisfied, you can talk to your insurance agent or discuss with a lawyer about the possibility to sue the insurance company.
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answered on Sep 18, 2019 at 13:59
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edited Dec 16, 2019 at 14:57
 
What this means is that the insurance company is saying that the your son was born with the problem in in his knee.
Yes.

 As you may know, insurance policies normally do not cover pre-existing problems or congenital problems. 
We don't know anything about my son knee problem... He was like normal person and active in sports. The injuries happened when his friend stepped on his leg while he was playing football.

MRI only shows the meniscus tear until the doctor found out that he had tear in discoid meniscus during operation time.

If you are still not satisfied, you can talk to your insurance agent or discuss with a lawyer about the possibility to sue the insurance company.
Look like this is the best way.

Thank you for your advice.
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answered on Oct 18, 2019 at 16:04
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edited Dec 16, 2019 at 14:58
 
@megan, what did your agent say about this?
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answered on Nov 8, 2019 at 15:25
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edited Dec 16, 2019 at 14:58
 
My insurance agent said that I can file a case against the insurance company. Now, I am trying to get the doctor report which was submitted to insurance company.
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answered on Mar 6, 2020 at 17:13
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Hi there, i had made a letter to insurance company and waiting them to reply.

.
 
Great Eastern Life Ass. (M) Bhd.
HealthCare Service Department,
Level 16, Menara Great Eastern,
303, Jalan Ampang ,
50450 Kuala Lumpur.
 
Dear Sir,
 
Appeal On Medical Card Claim Policy No. #########
 
Refering to the above, I appeal and would like to bring to your attention that my son’s medical claim has been declined for congenital reason. I strongly believe that my son deserve the medical claim for following reasons;
1.      My son had a fall during the Physical Education period in the school field under the supervision of a teacher after which he developed swelling and severe pain on his right knee.  The teacher has himself confirmed this in a letter given by school to me and a copy of this letter is attached for your attention.
2.       I took my son to Gleneagles Penang and saw an Orthopedic Surgeon who suggested that my son has meniscus injury with locked knee (as my son couldn't straighten his knee). He underwent urgent MRI and the diagnosis of meniscus tear was confirmed.
3.      We obtained approval from Great Eastern Life with the doctor’s clinical and MRI findings and after which the surgeon proceeded with surgery. The surgeon, radiologist or I were not aware of discoid meniscus until the surgery was done and prior to the surgery the discoid meniscus was symptomless and my son had no problem or complaint whatsoever.
4.      The surgeon discovered discoid meniscus during the surgery and wrote this in his report.
Based on the chronology of event, it shows clearly the treatment was needed due to his fall and not because of congenital reason and I feel that Great Eastern Life should approve the claim. Prior to this, the doctor has also spoken to the claims department but to no avail.

I hope you will approve this claim failing which I have no choice other than to refer to Bank Negara Malaysia for further assistance.
Thank you.
 

Yours sincerely,
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