Claims FAQs

Still have questions on claims? Get answers to the frequently asked questions here.
Customer Service lady

Frequently asked questions

Common Claims Illnesses
Am I covered for an admission for Minor Illnesses?

FAQ Minor Illness 

Which intraocular lens (IOL) can I pick if I’ve been diagnosed with cataract?

FAQ Cataract Medical Coverage 

What is FilmArray Respiratory Panel?

FAQ FilmArray Respiratory Panel 

Am I covered if I am in Cancer Remission stage?

FAQ Cancer Remission 

What is Day Surgery?

FAQ Day Surgery 

What is FilmArray Gastrointestinal Panel?

FAQ FilmArray Gastrointestinal Panel 

Claim forms, documents & submission
Who can certify claims documents?
  • Prudential Branch Officers

  • 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

  • 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

  • Stoma bag/Colostomy bag/Accu-check test strips and needles/Aerochamber

  • Diapers/Lining/Towels or similar items

  • 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

  • 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

  • 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

  • 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

  • Skin Allergy test/Skin Prick test/Mantoux test

5. Treatment that is elective, cosmetic and experimental in nature, including but not limited to:

  • Transconjunctival eye bag removal and similar nature of surgery

  • Vaginal rejuvenating laser or energy treatment

  • Laser coagulation for treatment of stress Incontinence

  • Circumcision/Preputioplasty/Hyperhidrosis/Staphylococcal Enterotoxin C Injection/Any kind of skin resurfacing using yag or carbon dioxide laser

  • Blood & adipose products injection (Stem cell/Blood products Injection)

  • Adoptive Immunotherapy and Cellular Therapy (Stem cell)

  • Lutetium 177 radioIsotope treatment

  • Pulsed Radiofrequency for chronic pain syndrome

  • Nerve block ie: Genicular nerve block and similar

  • 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.

  • Prostate Cancer with localized disease (T1 or T2 - Organ confined) as a primary therapy alternative to surgery or irradiation

  • Prostate Cancer with (locally advanced) or as salvage therapy for recurrent cancer following failure of radiation therapy

  • Malignant Endobronchial Obstruction

  • High risk individual for surgical intervention with Renal Cell Carcinoma, up to 4-cm in size

  • Drug resistant or intolerance Atrial fibrillation, with evidence of a localized site(s) of origin

  • Low-risk superficial Basal Cell Carcinoma or Squamous Cell Carcinoma in situ (Bowen disease), where surgery or radiation is contraindicated or impractical

  • Soft Tissue Sarcoma of the extremities or the trunk in symptomatic persons with disseminated metastases

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.

  • Bladder cancer

  • Recurrence post cystectomy, or for metastatic disease

  • Classical Hodgkin lymphoma

  • Colorectal cancer, small bowel adenocarcinoma, appendicle carcinoma, and anal adenocarcinoma

  • Head and neck cancer

  • Hepatocellular carcinoma

  • Kidney cancer

  • Malignant pleural mesothelioma

  • Melanoma

  • Metastatic squamous cell anal carcinoma

  • Non-small cell lung cancer (adenocarcinoma with mixed type)

  • Primary carcinoma of the urethra

  • Small cell lung cancer

  • Upper gastrointestinal tract tumors

  • Urothelial carcinoma of the prostate

Combined and Personalized Immunotherapy (CIC)

Pembrolizumab (Keytruda) are Immune checkpoint inhibitors drugs that remove obstacles from the immune system.

  • Urothelial carcinoma (Transitional cell carcinoma)

  • Bladder cancer

  • Primary carcinoma of the urethra

  • Upper gastrointestinal tract tumors

  • Urothelial carcinoma of the prostate

  • Colorectal cancer

  • Small bowel adenocarcinoma

  • Appendiceal carcinoma

Combined and Personalized Immunotherapy (CIC)

Cancer Vaccine Therapy known as Tumor-associated antigenic peptide-based vaccines for treatment of cancers.

  • Adult metastatic castrate-resistant Prostate cancer

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.

  • Chordomas or chondrosarcomas arising at the base of the skull or cervical spine without distant metastases; or

  • Malignancies in children (21 years of age and younger); or

  • Uveal melanomas confined to the globe (i.e. not distant metastases) (the uvea is comprised of the iris, ciliary body, and choroid [the vascular middle coat of the eye])

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.

  • Inoperable tumor; or

  • Locally advanced tumor especially in persons with gross residual disease; or unresectable tumor.

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.

  • Hodgkin's disease

  • Non-Hodgkin's lymphoma (NHL)

  • High risk stage II to stage III neuroblastoma & stage IV neuroblastoma primary recurrent or refractory disease (Primary refractory is defined as a tumor that does not achieve a complete remission after initial standard-dose chemotherapy. Relapse is defined as a tumor recurrence after a prior complete remission)

  • People with chemosensitive neuroblastoma who have relapsed after an autologous hematopoietic cell transplant.

  • People who have relapsed or progressive chemotherapy sensitive Ewing's sarcoma family of tumors that is not widely metastatic.

  • People with primitive neuroectodermal tumors (PNET) including medulloblastoma and pineoblastoma.

  • People with ependymoma who are ineligible for radiotherapy.

  • People with extraocular retinoblastoma

  • People with progressive or relapsed chemosensitive Wilms’ tumor.

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)

  • For treatment of intractable tremors as a consequence of Parkinson's disease with appropriate assessment of the independence in his/her daily life to meet the medical necessity.

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.

  • Femoral nerve blocks for acute postoperative pain after knee replacement surgery.

  • Intercostal nerve blocks for acute intercostal pain, and for chronic intercostal neuritis as part of a comprehensive pain management programme.

  • Peripheral nerve blocks (continuous or single-injection) for the treatment of (i) acute pain, and (ii) For chronic pain only as part of an active component of a comprehensive pain management programme.

  • Peripheral nerve blocks for the treatment of chronic pain post-herniorrhaphy to avoid more aggressive treatments (e.g. surgery).

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).

  • Facet joint injections (intra-articular and medial branch blocks) in persons with severe chronic neck and back pain. A set of facet joint injections (intra-articular or medial branch blocks) means up to 6 such injections per sitting, and this can be repeated once at the same levels and side, no sooner than one week after the initial set of injections.

  • Trigger point injections of corticosteroids and/or local anesthetics for treating members with chronic neck or back pain or myofascial pain syndrome.

  • Sacroiliac joint injections are considered medically necessary to relieve pain associated with lower lumbosacral disturbances. Interlaminar epidural injections of corticosteroid preparations (e.g. Depo-Medrol), with or without added anesthetic agents.

  • Chymopapain chemonucleolysis is considered medically necessary for the treatment of sciatica due to a herniated disc with the following criteria met:

  1. Person has leg pain worse than low back pain; and

  2. Person has radicular symptoms reproduced by sciatic stretch tests; and

  3. Person has only a single-level herniated disc with nerve root impingement at clinically suspected level demonstrated by MRI, CT, or myelography; and

  4. Person has objective neurologic deficit (e.g. diminished deep tendon reflex, motor weakness, or hyperalgesia in dermatomal distribution); and

  5. Person with pain not relieved by at least 6 weeks of conservative treatments

  • Percutaneous lumbar discectomy , manual or automated.

  • Non-pulsed radiofrequency facet denervation with intractable cervical or back pain with or without sciatica.

Brachytherapy

Also known as interstitial radiation, intracavitary radiation, internal radiation therapy)

  • Breast cancer

  • Esophageal cancer

  • Eye tumors

  • Genitourinary cancers other than bladder cancer (including penile cancer, prostate cancer, urethral cancer)

  • Gynecologic cancer (cervical, endometrial, vaginal or vulvar)

  • Head and neck cancers (including buccal mucosa cancer, lip cancer, mouth cancer, nasopharyngeal cancer, salivary gland cancer, soft palate cancer, tonsillar fossa/pillar cancer)

  • Respiratory and digestive tract cancers (including lung cancer for palliation of obstructive symptoms due to intraluminal tumor), pelvic recurrence of colorectal cancer, pleural mesotheliomas, rectal (anal cancer)

  • Skin cancer, where surgical resection and photon or electron beam techniques are contraindicated.

  • Soft tissue sarcomas

  • Stenotic obstruction post lung transplantation refractory to other treatments such as balloon dilation, laser debridement, or stent placement.


Note:

  1. This list is not exhaustive and is subject to revision by Prudential Assurance Malaysia Berhad, from time to time.

  2. 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.

  3. 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”)
  1. We will assess the reimbursement claim documents submitted to us according to the terms and conditions stated in your policy.

  2. 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.

  3. 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.)

  4. 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
  1. Ensure completion of claim forms and completeness of all documents to avoid unnecessary delay.

  2. Ensure your signature on the claim form tallies with the one in the records.

  3. Doctor's Statement is to be completed at the claimant's own expense.

  4. 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.

  5. 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:

  1. Through your agent

  2. Contact our Customer Service line at 03-21160228

  3. 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