Which Medical Expenses Are Covered Under Health Insurance?

Illnesses can be unexpected, happening to anyone at any time. Money is the last thing you should worry about when health issues and medical emergencies occur. However, the reality is that medical treatment, hospitalisation and rehabilitation can cost a lot, and many of us are unprepared to face the financial challenges that a serious illness can bring.

One of the most straightforward ways you and your family can obtain finances for medical expenses if the need ever arises is with health insurance. Nonetheless, there are instances and procedures that insurers do not cover. As such, it’s important to understand what health insurance policies cover and what they don’t.

What are medical expenses?

Medical expenses refer to the cost one has to pay for treating or preventing an illness, disease or injury. For example, doctor visits, hospital stays, medication, surgery, surgery aftercare, screening procedures, and even crutches and wheelchairs.

How to get money for medical expenses?

In Malaysia, one can choose to head to government-run medical facilities or private clinics and hospitals. While Malaysia's Health Ministry offers its citizens medical treatment at very low prices, government hospitals are usually overcrowded with long waiting queues.

Malaysians can also obtain medical care and treatment from private healthcare facilities. However, this can be incredibly costly. Depending on the hospital, medical condition, and treatment needed, a few days in the hospital may result in bills that are thousands of ringgit. Additionally, it’s been reported that Malaysia’s medical inflation rate is about 12% annually, which means that medical expenses will only continue to rise.

As such, many people are worried about paying for medical expenses if they get sick or are diagnosed with serious conditions. However, aside from paying the bills yourself, one of the best ways to ensure that you have the finances to cover medical expenses is to have health insurance.

What is health insurance?

Health insurance covers one’s healthcare expenses due to illnesses in exchange for a premium. For example, health insurance usually pays for hospitalisation costs, prescription drugs, and doctor’s consultation fees. Depending on the policy, the insurer will directly pay the healthcare provider or reimburse the policyholder for expenses incurred.  

What does health insurance cover?

It’s important to be aware of what a health insurance plan covers so that you don’t wind up in a bind over medical bills. Health insurance usually covers the following but might vary with different insurance providers and plans.

Hospital and doctor visits

Health insurance will cover most of the costs incurred from visits to your primary doctor and specialists. It will also cover hospital costs for treatment and procedures, emergency care, outpatient care, surgeries and overnight stays, as long as they are medically necessary. However, you’ll need to be aware of the clinics and hospitals that are in-network and head to those if you want to claim insurance.

Essential health benefits

Some health insurance policies may also cover the following, but you must check your policy to be sure:

• Ambulatory patient services

• Emergency services

• Treatment for mental health and substance use disorders

• Pregnancy, maternity and newborn care

• Preventive and wellness services (e.g. health screening)

• Chronic disease management

• Laboratory services

• Rehabilitative services and devices

 

Preventive health services

Preventive healthcare refers to the action and steps taken to prevent illnesses. For example, screening procedures to detect and, if necessary, treat diseases early.

Your health insurance should cover certain preventive health services, but you should check to be sure.

Prescriptions

You will most probably be able to claim health insurance for prescription medications that are indicated and approved to treat your medical condition(s).

Medical and health insurance exclusions

As with all types of insurance policies, health insurance also has exclusions. Some common exclusions include:

Pre-existing conditions

Pre-existing conditions - illnesses, diseases or health issues you had or still have before purchasing the policy are usually excluded from your cover.

However, some insurers allow coverage for pre-existing conditions but at higher premiums.

Qualifying or waiting period

Your insurer will not allow you to make any claims for medical conditions during the waiting period, usually 30 days from when you first buy the cover.

Cosmetic procedures

Health insurance does not cover cosmetic procedures to improve appearance unless it is deemed Medically Necessary. This includes surgeries with the aim of enhancing or reshaping body parts.

Fertility treatments

Fertility treatments such as in-vitro fertilization can cost thousands of ringgit. Unfortunately, health insurance does not cover fertility treatments.

Experimental or unapproved products and services

Your policy does not likely cover new technology that are still in research, experimental drugs or other unapproved products and services. If your doctors suggest such treatments, you should check with your insurance provider whether they’re covered, or you may have to pay for the incurred cost yourself.

Off-label prescriptions

Off-label prescriptions refer to medication used for purposes other than approved and intended. Your policy might not cover the cost of medication or treatment used this way, even if your doctor prescribes it.

How to check what my health insurance plan covers?

To check what your health insurance plan covers, you can sign in to your account at your insurer’s website or call your insurance company or insurance agent to ask. You must be clear about your health insurance to avoid paying for procedures and medication yourself.

What are out-of-pocket medical expenses?

Medical costs not covered by your insurer are considered out-of-pocket medical expenses. This means you will not be able to claim insurance and have to pay for it yourself. An example of out-of-pocket medical expense includes new medication not covered by your policy.

How to get insurance to cover medical expenses in Malaysia?

Purchasing health insurance to cover medical expenses in Malaysia is quite straightforward. All you need to do is to decide on the most suitable policy for yourself (and perhaps your family), have a medical check-up if needed, submit the necessary documents and start paying the premiums.

However, before buying health insurance, you should consider coverage, premium, panel hospitals, reimbursements, co-insurance, deductibles and guaranteed renewal. Remember that it's not just about how much you pay per month but how adequately your policy protects you. 

For more on factors to consider when buying health insurance, read ‘All You Need To Know About Getting Medical Insurance in Malaysia.’

How to claim health insurance in Malaysia?

The health insurance claim process is quite simple, although it can be rather daunting if it’s your first time doing so. Here are some tips to help avoid delays:

1. Call your insurance provider or agent to check if your policy covers the treatment you're about to receive. Also, check if the hospital you’re receiving treatment at is in-network and part of the company’s panel of hospitals.

2. Ask your doctor to fill out and sign the claim forms. You will probably be able to obtain the forms on your insurer’s website.

3. Be aware that there are different claim methods. For example, some insurance companies reimburse medical expenses when you submit the receipts to make a claim. Other insurers issue a hospital guarantee letter that allows the insured cashless admission privilege. If you’re admitted at a non-panel hospital, you’ll likely have to pay the bill first and then make your claims.

4. Submit all necessary documents, such as your doctor’s report and original bills to your insurance company as soon as possible. Ask your insurance agent if you're unsure of how and what to submit. This is an important step as the claim process is often slowed or even denied when submissions are incomplete.

For more on claiming insurance, read ‘Insurance Claims Procedures: Understanding the Insurance Claims Process.’

Is health insurance worth it?

Paying a monthly premium to your insurer might seem like a waste of money, but illnesses and health issues can happen to anyone at any time. A week of treatment and hospital stay in Malaysia at a private hospital can cost thousands of ringgit, depending on your health condition.

As such, it is better to be prepared and protected financially than having to dip into your life savings when there is a medical emergency. After all, you don't want to spend the money you've been saving to buy a home, your child's education or your retirement on medical expenses.

Conclusion

Health insurance will help you financially if, unfortunately, you get sick and are hospitalised. If you’re looking for a reliable and comprehensive health insurance plan, Prudential has both individual and family health insurance plans that will meet your and your family’s needs.