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Medical Card: What's Not Covered

Getting hospitalized or receiving medical treatment can be very costly in Malaysia. Hence, many rely on medical cards from insurance providers like Prudential to help cover these expenses. However, there are certain things that medical cards do not cover. Understanding the exclusions is crucial to avoid any surprises or confusion when making a claim.

1. Pre-Existing Medical Conditions

This is the most common exclusion in medical cards. Pre-existing conditions refer to any illnesses, diseases, injuries, or conditions that you already had before purchasing the medical card. For example, if you had diabetes before buying the policy, hospital charges related to diabetes will not be claimable.

This exclusion is implemented because insurance aims to protect against future uncertainties. If policyholders could claim for illnesses they already have, it would go against the inherent purpose of insurance and increase costs for all parties.

However, pre-existing conditions may still be covered if you have notified the insurance company beforehand and they have explicitly agreed to provide coverage. But this will likely involve additional premiums and declarations.

2. Waiting Periods

Most medical cards also have initial waiting periods during which you cannot make claims yet. Two main examples:

a)  Specific Illness Waiting Period

There is usually a 120-day waiting period for certain specified illnesses like hypertension, kidney stones, tumors, etc. Any treatment for these conditions incurred within the first 120 days will be excluded.

For example, if you unfortunately discover a tumor 50 days after purchasing a policy, you will not be able to claim for the treatment costs yet until after 120 days has passed. This prevents people from buying insurance only when they discover an illness.

b) General Waiting Period

There is also commonly a 30-day general waiting period for non-specified conditions. So any hospitalization or treatment within the first month will be excluded, except for accidental injuries.

This prevents people from immediately making claims for medical services they already planned to receive before buying insurance just to have it paid for.

3. Congenital Conditions

Congenital conditions refer to abnormalities and birth defects that a person is born with, such as a hole in the heart. Treatments to fix these congenital conditions are excluded and cannot be claimed.

For example, a child born with a cleft lip could not claim surgery to repair it under a medical card. This exclusion exists because congenital conditions are pre-existing from birth itself.

4. Cosmetic Procedures

Cosmetic surgeries or treatments done to improve one's appearance, like botox injections and nose jobs, cannot be claimed as they are not medically necessary.

Exceptions are reconstructive procedures to restore function and physical appearance after an injury, trauma or illness, as those can be claimed.

5. Dental Care

Dental treatments are commonly excluded, though some basic procedures may be covered under certain plans. Extensive dental work like crowns, implants, and orthodontics cannot be claimed.

The only exception is if dental treatment is necessary due to a facial injury from an accident that also damaged the teeth. However regular dental issues unrelated to accidents are excluded.

6. Maternity-Related Expenses

Normal pregnancy and delivery cannot be claimed. However, many plans provide coverage for maternity complications that arise, such as ectopic pregnancy or pre-eclampsia requiring emergency treatment.

Routine check-ups and tests during pregnancy would be excluded, as those do not constitute complications. But emergency procedures needed due to complications can be claimed.

7. Alternative Treatments

Alternative therapies like traditional Chinese medicine (TCM), ayurveda, homeopathy, and treatments like acupuncture or reflexology are commonly excluded or have limited coverage.

For example, a policy may only pay up to RM100 per visit for acupuncture treatments. Or it may cap the total claimable amount for TCM to RM3,000 per year. Hence, review the fine print to understand what exceptions may apply.

8. Experimental Treatments

New medical technologies or procedures that are still deemed experimental or unproven are excluded. Policyholders cannot claim for treatments that have not been approved yet by health authorities or accepted by the general medical community.

For example, some forms of immunotherapy for cancer are still considered experimental in Malaysia, so the costs may not be claimable yet until the treatment becomes mainstream.

Frequently Asked Questions (FAQs)

Q: Can I claim for medical check-ups?

A: No, general medical check-ups cannot be claimed as they do not treat any illness or condition. Some policies may provide limited coverage for specific screening tests like mammograms or pap smears.

Q: What if I didn't know about an illness when I bought the policy?

A: You cannot claim for that illness as it would still fall under pre-existing conditions. A lack of diagnosis does not make the underlying condition itself not pre-existing.

Q: Can I get coverage for my chronic illnesses?

A: Yes, but you need to inform the insurance company about it. They will decide if coverage can be offered by charging higher premiums or imposing other terms.

Q: Do waiting periods apply for policy renewals too?

A: No, waiting periods are only applicable in the first policy year. Subsequent renewals will provide full coverage without having to go through waiting periods again.

Q: If I fall sick overseas, does my medical card cover that?

A: Yes, hospitalization and treatment overseas are often covered but with limitations or caps. Things like emergency medical evacuation may have lower limits too. Always check your policy terms.

The key is not to assume everything will be covered under your medical card. Go through the policy contract thoroughly and clarify any doubts or grey areas to avoid misunderstandings later. It is always better to be clear upfront on what is claimable and what is not.

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