Medical and health insurance (MHI), is an insurance policy which is designed to cover the cost of private medical treatment, which can be very expensive, especially with hospitalisation and surgery. MHI also ensures that you won't have to worry about the cost of seeking treatment during emergencies. In addition, MHI also provides you with an income stream while you undergo treatment.
 
Related Information

Are you covered?

Types of insurance plans

Dealing with intermediaries

Medical and health takaful

How do i make a complaint?
 
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  The medical & health insurance (MHI) policy is a legal contract, and the meanings used in the policy will apply when a claim is made. That is why it is important that you read and understand the terms used in a MHI policy. If you still do not understand them fully, ask your insurance agent or company to explain them to you.

Your policy contract will have the actual definitions for the terms used in the contract. They generally will be the legal meanings, so you have to read and understand them carefully. Ask your insurance agent or company what they mean, if you do not understand them fully.

The following list is some of the more important terms used, but are not the legal definitions used in your contract. You may refer to your policy contract for the actual definition:
 
     
 
Pre-existing conditions
 
These refer to conditions or illnesses that existed before the effective date of a MHI policy, for which you are receiving treatment or have shown symptoms. It does not matter whether you were aware of them or not. If you consulted a medical doctor for any pain or discomfort in connection with the condition, it would be regarded as a symptom of a disability.
 
Co-payment
 
If you are hospitalised and the board rate is higher than your eligibility, you will bear the difference in the room charges as well as some portion (usually between 10% - 20%) of the other eligible benefits described in the policy contract.
 
 
Qualifying/waiting period
 
Most MHI policies contain a waiting period for illness and disease, which means that eligibility for benefits under the policy will only start 30 days after the effective date of the policy.
 
Free-look period
 
If you decide not to take up a MHI policy, you can cancel the policy by returning it to the insurance company within 15 days from the date of issue. You will be entitled to a refund of the full premium, after deducting administrative expenses incurred by the insurance company for issuing the policy. These expenses shall be RM50 or 10% of the gross premium paid, whichever is lesser.
 
 
Overseas treatment
 
 
You may or may not be covered for treatment obtained overseas, subject to the exclusions, limitations and conditions specified in the policy contract.
 
Misstatement of age
 
Your age is an important rating factor in your MHI policy. If you have misstated your age and the premium paid as a result is not enough, any claim payable under the policy will be pro-rated, based on the ratio of the actual premium paid to the correct premium that should have been charged.

That means you will only receive part of your claims, instead of the total amount incurred.
 
Residence overseas
 
If you were to live or travel out of Malaysia for more than 90 consecutive days, no benefits will be payable for medical treatment outside Malaysia.
 
 
     
     
     
 
Just like other insurance policies, MHI policies can also contain exclusions. You must be aware what these exclusions are. If you do not understand any of these exclusions, ask your insurance agent or company to explain them. Here are some common exclusions:  
 
     
Pre-existing conditions
     
 
Conditions and illnesses experienced by you prior to applying for the policy. These conditions and illnesses would be excluded from coverage by your insurance company. You should check with your insurance company regarding the details of pre-exisitng conditions for the policy that you intend to buy.  
 
     
Specified illnesses
     
 
These are defined as 12 disabilities (e.g. tumours and gastritis) and their related conditions. You will not be covered for these illnesses if the illnesses have been treated or occurred during the first 12 months of your policy.
 
 
     
Qualifying/waiting period
     
 
You will not be eligible for any claim arising from any medical or physical conditions within the first 30 days of the cover, except for accidental injuries.
 
 
     
     
  When you want to renew your policy, the insurance company might take one of the following decisions:  
     
 
Renew the policy with a level premium;

Renew the policy with an increased premium; or
Decline to renew the policy.
  Your insurance company is required to provide you with the reason for its decision on a change in the premium level or why a policy is not renewed.

If you are unsatisfied with the insurance company’s reasons, you may wish to file a complaint. Find out how to make a complaint here.
 
     
     
  Making a claim from a medical & health insurance (MHI) policy can be hassle-free if you know what to do and what your responsibilities are. Some important points relating to claims are as follows:  
     
 
 
Before you receive any non-emergency treatment, check with your insurance company if the treatment is covered by your policy or if the hospital is the insurance company’s panel hospital. In fact some insurance companies insist you do this.
 
Your doctor/specialist will probably need to fill in and sign your claim form. Your doctor may charge a small fee, which will not be covered by your insurance.
 
Stay in contact with your insurance company on the status of your claim.
 
Your specialist may recommend tests or admission to hospital as in-patient.
 
Most hospitals and some specialists have their bills paid directly by the insurance company. Others will send the bills to you.
   
Your insurance company will give you all the guidance you need, confirm what your cover includes and, if necessary, send you a claim form.
 
Your insurance company will tell you how they pay claims.
 
 
 
     
   
  If you are diagnosed with a disability that incurs claimable expenses, you should do the following:  
     
 
 
Give written notice to your insurance company as soon as possible, or within 30 days of the treatment received.
 
 
Attach the following:

All original bills & receipts
(copies will not be accepted)

Full report by physician

Physician’s summary of the cost of treatment

Referral letter (if any)
 
 
Immediately get and act on proper medical advice as the insurance company will not be held liable if a treatment or service becomes necessary because you delayed treatment or failed to act on the medical advice.
 
 
 
     
  Important Note:  
     
  Benefits are payable only if all bills for such claims have been submitted and agreed upon by the insurance company.

The insurance company will consider reimbursing only the actual costs incurred subject to the limits of the policies.
 
 
 
 
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For more information on medical and health insurance, please download our booklet or contact
an insurance company to learn about medical and health insurance.