Claims FAQs

Frequently asked questions
Common Claims Illnesses
Am I covered for an admission for Minor Illnesses?
Which intraocular lens (IOL) can I pick if I’ve been diagnosed with cataract?
What is FilmArray Respiratory Panel?
FAQ FilmArray Respiratory Panel
Am I covered if I am in Cancer Remission stage?
What is Day Surgery?
What is FilmArray Gastrointestinal Panel?
Serious Conditions
What is Serious Condition?
A Serious Condition shall mean any one of the following illnesses as defined below. It is applicable for policy attached with PRUValue Med Booster or PRUMillion Med Booster only. If you are hospitalised due to any serious condition below and require any post-hospitalisation support (including outpatient physiotherapy) after your discharge from the hospital, you are eligible to receive the post-hospitalisation support up to 365 days.
Important note: Eligibility of the claim would be subjected to your policy terms and conditions.
List of Serious Condition
Serious Condition |
Definition |
Stroke – resulting in Permanent neurological deficit with persisting clinical symptoms |
Death of brain tissue due to inadequate blood supply, bleeding within the skull or embolization from an extra cranial source resulting in Permanent neurological deficit with persisting clinical symptoms. The diagnosis must be based on changes seen in a CT scan or MRI and certified by a neurologist. For the above definition, the following are not covered: (i) Transient ischemic attacks (ii) Cerebral symptoms due to migraine (iii) Traumatic injury to brain tissue or blood vessels (iv) Vascular disease affecting the eye or optic nerve or vestibular functions. |
Paralysis of Limbs |
Total, Permanent and Irreversible loss of use of both arms or both legs, or of one arm and one leg, through paralysis caused by illness or injury. |
Heart Attack |
Death of heart muscle, due to inadequate blood supply, that has resulted in all of the following evidence of acute myocardial infarction: (i) A history of typical chest pain; (ii) New characteristic electrocardiographic changes; with the development of any of the following: ST elevation or depression, T wave inversion, pathological Q waves or left bundle branch block and (iii) Elevation of the cardiac biomarkers, inclusive of CPK-MB above the generally accepted normal laboratory levels or Troponins recorded at the following levels or higher:
The evidence must show the occurrence of a definite acute myocardial infarction which should be confirmed by a Doctor or Physician. |
Coronary Artery By-Pass Surgery |
Refers to the actual undergoing of open-chest surgery to correct or treat Coronary Artery Disease (CAD) by way of coronary artery by-pass grafting. For the above definition, the following are not covered: (i) angioplasty; (ii) other intra-arterial or catheter based techniques; (iii) keyhole procedures; (iv) laser procedures. |
Serious Coronary Artery Disease |
The narrowing of the lumen of Right Coronary Artery (RCA), Left Anterior Descending Artery (LAD) and Circumflex Artery (not inclusive of their branches) occurring at the same time by a minimum of sixty percent (60%) in each artery as proven by coronary arteriography (non-invasive diagnostic procedures are not covered). A narrowing of sixty percent (60%) or more of the Left Main Stem will be considered as a narrowing of the Left Anterior Descending Artery (LAD) and Circumflex Artery. This covered event is payable regardless of whether or not any form of coronary artery surgery has been performed. |
Angioplasty and Other Invasive Treatments for Coronary Artery Disease |
The actual undergoing of Coronary Artery Balloon Angioplasty, artherectomy, laser treatment or the insertion of a stent to correct a narrowing or blockage of one or more coronary arteries as shown by angiographic evidence. Intra-arterial investigative procedures are not covered. |
Heart Valve Surgery |
The actual undergoing of open-heart surgery to replace or repair cardiac valves as a consequence of heart valve defects or abnormalities. For the above definition, the following are not covered: (i) Repair via intra-arterial procedure (ii) Repair via key-hole surgery or any other similar techniques. |
Cancer – of specified severity and does not cover very early cancers |
Any malignant tumour positively diagnosed with histological confirmation and characterized by the uncontrolled growth of malignant cells and invasion of tissue. The term malignant tumour includes leukemia, lymphoma and sarcoma. For the above definition, the following are not covered: (i) All cancers which are histologically classified as any of the following:
(ii) All tumours of the prostate histologically classified as T1N0M0 (TNM classification) (iii) All tumours of the thyroid histologically classified as T1N0M0 (TNM classification) (iv) All tumours of the urinary bladder histologically classified as T1N0M0 (TNM classification) (v) Chronic Lymphocytic Leukemia less than RAI Stage 3 (vi) All cancers in the presence of HIV (vii) Any skin cancer other than malignant melanoma. |
Brain Surgery |
The actual undergoing of surgery to the brain under general anesthesia during which a craniotomy (surgical opening of skull) is performed.For the above definition, the following are not covered: (i) Burr hole procedures (ii) Transphenoidal procedures (iii) Endoscopic assisted procedures or any other minimally invasive procedures (iv) Brain surgery as a result of an Accident. |
Encephalitis – resulting in Permanent inability to perform Activities of Daily Living |
Severe inflammation of brain substance, resulting in Permanent functional impairment. The Permanent functional impairment must result in an inability to perform at least three (3) of the Activities of Daily Living. The covered event must be certified by a neurologist. Encephalitis in the presence of HIV infection is not covered. |
Parkinson’s Disease – resulting in Permanent inability to perform Activities of Daily Living |
A definite diagnosis of Parkinson's Disease by a neurologist where all the following conditions are met: (i) Cannot be controlled with medication; (ii) Shows signs of progressive impairment; and (iii) Confirmation of the Permanent inability of the Insured Life to perform without assistance three (3) or more of the Activities of Daily Living. Only idiopathic Parkinson's Disease is covered. Drug-induced or toxic causes of Parkinsonism are not covered. |
Alzheimer’s Disease/Severe Dementia |
Deterioration or loss of intellectual capacity confirmed by clinical evaluation and imaging tests arising from Alzheimer's Disease or Severe Dementia as a result of Irreversible organic brain disorders. The covered event must result in significant reduction in mental and social functioning requiring continuous supervision of the Insured Life. The diagnosis must be clinically confirmed by a neurologist. From the above definition, the following are not covered: (i) Non organic brain disorders such as neurosis (ii) Psychiatric illnesses (iii) Drug or alcohol related brain damage |
Systemic Lupus Erythematosus with Severe Kidney Complications |
A definite diagnosis of Systemic Lupus Erythematosus confirmed by a rheumatologist. For this definition, the covered event is payable only if it has resulted in Type III to Type V Lupus Nephritis as established by renal biopsy. Other forms such as discoid lupus or those forms with only hematological or joint involvement are not covered. WHO Lupus Classification: Type III - Focal Segmental glomerulonephritis |
Crohn’s Disease with Intestinal Fistula, Obstruction or Perforation |
Crohn’s Disease is a chronic granulomatous inflammatory bowel disease. Crohn’s Disease must have resulted in fistula formation, or intestinal obstruction or intestinal perforation that has required surgery and continuous immunosuppressive treatment or continuous treatment with immunomodulating drugs. Crohn’s Disease must be proven on biopsy and there must be continuous treatment under the care of a gastroenterologist. |
Serious Accident - including Major Head Trauma with Permanent inability to perform Activities of Daily Living |
Inability to perform at least three (3) of the Activities of Daily Living resulting from serious accident. |
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Updated as of 24 Jun 2022
Note: The above list is not exhaustive and is subject to revision by Prudential Assurance Malaysia Berhad from time to time. If you have any enquiries, please email to Prudential at customer.mys@prudential.com.my.
Claim forms, documents & submission
Who can certify claims documents?
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Prudential Branch Officers
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Prudential Business Development Executive/Manager
Where can I obtain the claims form required for submission?
You may contact your agent or Customer Service at 03-2116 0228 or you can also write to us at customer.mys@prudential.com.my
How do I submit my claim?
You may submit the completed forms and supporting documents to us via your agents or directly to any Prudential branch
What happens after I submit my claim?
Once a claim has been submitted to us, we will assess it based on the terms and conditions of the policy. When a decision has been made or if we require further clarification or details so that we can assess your entitlement to the claim, we will notify you in writing.
How do I check the progress of my claims submission?
Once a claim has been submitted to us, you may contact your agent, Customer Service at 03-2116 0228 or write to us at customer.mys@prudential.com.my for more information on your claims progress.
If my employer/other insurer does not cover my medical expenses in full, can I claim the balance under my Prudential policy?
Yes. You may submit your claims documentation to us and we will assess it in accordance with your policy terms and conditions. Please refer to the amount that was not covered by your employer/other insurers for the document requirements.
What are the types of documents that I need to submit to prove registration of an allied health professional or traditional and complementary medicine practitioner?
As long as the evidence of registration is recognised under the law or by the authorities, we will accept that document as proof of registration.
I want to submit a claim for total and permanent loss of use of a body part due to an accident. Even though my policy has a table of benefits that specifies benefit percentage based on loss of use of a particular body part, I could not find this body part from the table. Can I still submit the claim?
Yes, and we will assess the claim based on the terms and conditions of your policy. If you are entitled to the claim, we will assess then based on a percentage that is not inconsistent with existing table in your policy.
Claims reassessment & claims payout
Can I appeal for a reassessment?
You may write in your appeal, together with relevant supporting documents for us to reassess your claims again.
How long will I have to wait for my claims payout?
The time taken depends on the complete-ness of the documentation received.
Whose name will the claims payout be issued under?
For death claims, the claims payout will be issued to the beneficiary or the assignee of the policy. For life claims, the claims payout will be issued to the assured/policy owner or the assignee of the policy.
Co-insurance & HAS waiting period
What is co-insurance?
Co-insurance is a cost-sharing arrangement between you and the insurer whereby you will need to pay a specified percentage of the cost of your eligible benefit.
What is HAS?
HAS waiting period is applied within the first 90 days from policy cover date in which no Guarantee Letter facility is available except for accident cases. However, claims can still be submitted under reimbursement basis subject to terms and conditions.
Pre-hospitalisation & post-hospitalisation
What is Pre-hospitalisation?
Pre-hospitalisation refers to the expenses incurred at the clinic/hospital prior to your admission to the hospital.
E.g. you consulted your nearby clinic for fever and your doctor referred you to be admitted to the hospital for dengue fever. In this scenario, you may claim for the clinic consultation payment under pre-hospitalisation.
Important note: Eligibility of the claim would be subjected to your policy terms and conditions.
What is Post-hospitalisation?
Post-hospitalisation refers to the expenses incurred at the specialist clinic/hospital after your admission and subsequent discharge from the hospital.
E.g. After your discharge from the hospital, you go for a follow-up with your doctor. In this scenario, the payment for the follow-up will be part of the post-hospitalisation expenses.
Important note: Eligibility of the claim would be subjected to your policy terms and conditions.
Tip: if your follow-up is with a different doctor, please ask the doctor to indicate on the receipt the diagnosis and the type of treatment endorsed by the doctor.
Emergency & Accidental Treatment (EAT)
What is Emergency & Accidental Treatment (EAT)?
EAT refers to consultation and medical expenses incurred upon an accident. For example, you suffer injuries due to an accidental fall and seek treatment for the injuries sustained.
Important note: Only applicable if medical treatment is sought within 48 hours from the accident and for expenses incurred within 30 days from the date of the accident.
Tip: if your medical bills are below RM500.00, please ask the doctor to indicate the date of the accident, nature of the accident, and the type of treatment on the receipt
Non-claimable items
What are the claim items that are not covered and considered not as customary under Prudential medical benefits?
List of Non-Claimable Items
Prudential covers all costs directly related to the treatment of the covered conditions. However there are certain things that Prudential does not cover as per below:
1. Stationery or services provided by a hospital that is not directly related to treat the medical condition or illness
- Admission & registration fees/Medical report & medical record fees
- Telephone/Fax/Mail/Computer/Electric/Billing processing related charges
2. Home care or take home external appliances that can be purchased from retail store or pharmacy without prescription
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Crutches/Shoulder crutch/Folding walker/Walking frame/Walking stick/Wheelchair/Ice pack and ice bag cover/Wrist aid support/Lumbosacral support/Lumbar corset (any back and spine patient)/Knee brace/Knee immobilizer/Arm-sling/Cervical support/Jewett brace/Neck collar/Ankle support/Embolism stocking/TED stocking/Stockinette
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Stoma bag/Colostomy bag/Accu-check test strips and needles/Aerochamber
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Diapers/Lining/Towels or similar items
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Any kind of facial cleanser/Body and hair shampoo and scar gel or any form of moisturizer
3. Vitamins or supplements to promote health or enhance bodily functions
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Including but not limited to Neuroaid/Ginko/Sangobion/ Tanakan/Neurobion/Ostinol/Calcium/Revicon/Hexbio/ Legalon/Cefasily/Livolin forte/Fibre sachet/Omega fish oil/ Bio-Quinone/Essential Forte & Piascledine/Folic acid/Iberet folic/Arcalion/Adaxil /Probiotics/Any supplement containing active ingredient of Glucosamine or similar
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Any kind of infant's or adult's nutrition formula
4. Investigation (Lab, Imaging or of any other kind) that is not covered under the medical benefit and/or done for Screening purpose
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May including and not limited to Sexually transmitted disease test/Pregnancy test/Infertility test/Genome test/Somatic DNA targeted Sequencing Panel/Hepatocyte growth-promoting factors/Circular RNA and Polymerase Chain Reaction (CR & PCR test)/RNA fusion analysis/Peptide Receptor Radionuclide test (PRR test)/Paradigm Cancer Diagnostic (PCDx)/Genome test/Molecular profiling/Cancer marker
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Skin Allergy test/Skin Prick test/Mantoux test
5. Treatment that is elective, cosmetic and experimental in nature, including but not limited to:
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Transconjunctival eye bag removal and similar nature of surgery
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Vaginal rejuvenating laser or energy treatment
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Laser coagulation for treatment of stress Incontinence
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Circumcision/Preputioplasty/Hyperhidrosis/Staphylococcal Enterotoxin C Injection/Any kind of skin resurfacing using yag or carbon dioxide laser
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Blood & adipose products injection (Stem cell/Blood products Injection)
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Adoptive Immunotherapy and Cellular Therapy (Stem cell)
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Lutetium 177 radioIsotope treatment
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Pulsed Radiofrequency for chronic pain syndrome
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Nerve block ie: Genicular nerve block and similar
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Robotic Surgery for cardiac/gastrointestinal/urology/gynecological etc. (except Prostate cancer, based on pre-authorization assessment consideration)
Note: The above list is not exhaustive and is subject to revision by Prudential Assurance Malaysia Berhad from time to time. If you have any enquiries, please email to Prudential at customer.mys@prudential.com.my
Advanced Treatment claimable items
What are the Advanced Treatment claim items that are covered under Prudential medical benefits?
List of Advanced Treatments Coverable Under Medical Benefits
Advanced Treatment |
Coverable Conditions |
Cryoablation Primary therapy alternative to surgery for individuals with localized disease or as a salvage therapy for recurrent cancer following failure of radiation therapy. |
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Combined and Personalized Immunotherapy (CIC) Nivolumab (Opdiva) are man-made monoclonal antibodies versions of immune system proteins designed to bind to specific targets in the body and causes immune response that destroys cancer cells. |
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Combined and Personalized Immunotherapy (CIC) Pembrolizumab (Keytruda) are Immune checkpoint inhibitors drugs that remove obstacles from the immune system. |
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Combined and Personalized Immunotherapy (CIC) Cancer Vaccine Therapy known as Tumor-associated antigenic peptide-based vaccines for treatment of cancers. |
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Proton Beam Radiotherapy (PBRT) Proton beam radiation therapy (PBRT) is a type of external beam radiation therapy (EBRT) that utilizes protons (positively charged subatomic particles) that are precisely targeted to a specific tissue mass. |
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Neutron Beam Radiation Therapy (NBRT) Neutron beam radiation therapy (NBRT) is a specialized type of EBRT that uses high energy neutrons (neutral charged subatomic particles) targeted toward tissue masses that are characterized by lower tumor oxygen levels and a slower cell cycle as neutrons require less oxygen and are less dependent on the cell’s position in the cell division cycle. |
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Stem Cells for Hematopoietic Cell Transplant Bone marrow harvested from compatible donors to obtain the stem cells or bone marrow name as allogeneic bone marrow or peripheral stem cell transplant. |
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Deep-Brain Stimulation (DBS) Unilateral or bilateral deep brain stimulators (e.g. stimulation of the ventral intermediate thalamic nucleus, globus pallidus, and subthalamic nucleus) criteria with Durable Medical Equipment (DME) |
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Nerve Block A nerve block is a form of regional anesthesia. Peripheral nerve blocks (PNBs) entail the injection of corticosteroids, local anesthetics, neurolytic agents and/or sclerosing agents into or near peripheral nerves or nerve ganglion resulting in the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks (somatic and sympathetic nerves). Peripheral nerve blocks attempt to block pain signals and in theory provide prolonged relief from pain. |
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Back Pain (Invasive procedures) Procedures that used to treat chronic pain that an individual especially at neck and back bone that limit daily activities and has lasted more than 3 months despite appropriate conservative treatment (including, but not limited to rest, systemic medications, and/or physical therapy). |
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Brachytherapy Also known as interstitial radiation, intracavitary radiation, internal radiation therapy) |
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Note:
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This list is not exhaustive and is subject to revision by Prudential Assurance Malaysia Berhad, from time to time.
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The above advanced treatments are covered by Prudential Assurance Malaysia Berhad for the above stated health conditions ONLY. In the event, the above advanced treatment is sought for any conditions other than above, as advised by your Attending Doctor, please seek confirmation on the coverage.
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The above treatment will be covered under the medical plan subject to terms & conditions as specified in the policy contract.
For more enquiries, please email: customer.mys@prudential.com.my
Overseas treatment claims
If I am admitted overseas, will I still be able to claim back the expenses incurred?
For overseas medical expenses, please submit your claim and we will assess it according to the terms and conditions stated in your annexure.
Oversea Treatment Claim (“OTC”)
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We will assess the reimbursement claim documents submitted to us according to the terms and conditions stated in your policy.
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If the Life Assured has been residing outside of Malaysia for more than ninety (90) days on each trip, any OTC claim is not accepted.
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Any OTC payment is subject to what is understood as Medically Necessary, and based on the Reasonable and Customary Charges (“RCC”) for equivalent local treatment in Malaysia. (Please refer to the OVERSEAS TREATMENT clause in your policy.)
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Processing of OTC may take longer compared to other claims as we need to make an accurate assessment of RCC of equivalent local treatment in Malaysia.
Important notes before claims submission
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Ensure completion of claim forms and completeness of all documents to avoid unnecessary delay.
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Ensure your signature on the claim form tallies with the one in the records.
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Doctor's Statement is to be completed at the claimant's own expense.
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The checklist provides a reference of the point-of-submission requirements only. The company reserves the right to request for other relevant documents and information.
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The company may request to view the original of copied documents submitted whenever necessary.
You may submit the completed form(s) and supporting documents to us via your agent or at the nearest Prudential branch.
Claims status enquiries
You may check the status of your submitted claim via the following options:
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Through your agent
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Contact our Customer Service line at 03-21160228
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Send us an email at customer.mys@prudential.com.my
Note: The above information serves as a guide. In the event that you have any queries on the above, kindly contact your agent or our Customer Service at 03-21160228 or write to us at customer.mys@prudential.com.my