When you buy a medical card, the person you trust the most is usually your insurance agent. Most Malaysians assume that if something goes wrong during a hospitalisation or claim, the agent will step in, solve the issue, and speak directly to the insurer on their behalf.
However, a recent report highlighted a truth that surprises many policyholders: insurance agents have no formal role in the medical claims process. While this is technically correct from the insurers’ point of view, the real-world experience of Malaysian policyholders is far more complex. And this gap between expectation and reality is often where frustration begins.
As someone actively helping Malaysians choose the right medical card, here is a transparent, agent-focused explanation of how claims actually work — and how you can protect yourself from unnecessary delays. From my own point of view, insurance agents still provide a huge amount of value bridging the gaps for our customers who have close to no understanding on how the claims process works.
1. What LIAM Says: Agents Are Intermediaries, Not Decision-Makers
LIAM CEO Mark O’Dell says insurance agents don’t have a formal role in the medical claims process that’s managed by insurer officers. Wanting to meet claims staff isn’t unreasonable but it “remains the decision of the insurer whether to meet the claimant.”
The medical claims process is entirely managed by internal officers within insurance companies. These officers — not agents — review medical reports, verify conditions, consult underwriting guidelines, and approve or reject claims.
Agents can communicate, assist, and follow up, but they do not have authority to:
- Approve claims
- Reverse a rejection
- Override underwriting rules
- Force a claims officer to meet or speak to a customer
This explains why most insurers do not publish the contact details of their claims personnel. The communication channel is intentionally centralised to maintain consistency, reduce errors, and prevent direct pressure on claims staff.
2. So Why Do Agents Still Help You During Claims?
Even if the official rule says we have “no formal role,” the reality is simple:
Most agents step in because clients need help at their most vulnerable moment.
When someone is sick, stressed, or hospitalised, they often do not have the emotional capacity to deal with paperwork, diagnosis codes, and medical terminology. That is why agents voluntarily:
- Chase hospitals for discharge summaries
- Explain why insurers request certain documents
- Clarify exclusions and waiting periods
- Check policy benefits and limits
- Help clients understand what is reimbursable
- Follow up repeatedly on “pending” cases
- Provide reassurance when a client feels worried or lost
These actions are not part of our commission contract. We do them because we want clients to feel supported — especially when facing serious illnesses like cancer, heart disease, or accidents.
3. Why Direct Access to Claims Officers Is Rare
Many clients wonder why they can’t speak directly to the person handling their file.
The reason is systemic:
Claims officers are trained specialists who handle hundreds of cases daily. It’s best to minimise pressure from the insured so that claims processes can be done impartially.
Allowing direct public access would overwhelm them, delay decisions, and expose them to potential confrontation in emotionally charged situations.
Instead, insurers use:
- A central claims email
- A customer service hotline
- A structured review workflow
Your agent often becomes the bridge, helping translate insurer feedback into something customers can understand.
4. Common Reasons Medical Claims Get Delayed
From experience, most delays are not because insurers intend to avoid paying. They usually happen because:
A. Missing or incomplete medical reports
Hospitals do not always issue detailed reports unless specifically requested.
B. Diagnosis codes not clearly stated
Insurance companies rely on ICD/ICD-10 codes. If doctors use vague wording, insurers must verify.
C. Investigation of pre-existing conditions
If there were past episodes of hypertension, diabetes, gastric issues, lumps, or abnormal scans, insurers will request older records.
D. Waiting periods or non-disclosure concerns
If something appears to be within the initial waiting period, insurers will check carefully.
E. Chronic conditions not previously declared
This is especially common in claims involving cancer, heart disease, or kidney issues.
These delays do not automatically mean the claim will be rejected, but they do extend the processing timeline, and a good insurance agent will assist you in navigating these unfamiliar territories.
5. What Policyholders Can Do To Speed Up Their Claims
Many headaches can be avoided if clients prepare these early:
Keep all past medical records
Old clinic visits, previous scans, blood tests — these can become crucial if an insurer needs verification.
Tell your doctor you are claiming insurance
Doctors can write clearer diagnosis notes when they know it is for an insurer.
Notify your agent immediately after any hospital admission
Even simple outpatient procedures can trigger claim investigations later.
Submit itemised bills and full discharge summaries
Incomplete documents almost always lead to insurer requests for more information.
Be upfront about previous health conditions before buying a policy
Full disclosure leads to clearer underwriting and fewer disputes later.
6. What Agents Can Realistically Do (So Expectations Are Fair)
To set healthy expectations, here is what agents can do:
- Guide you through the correct documents to submit
- Explain policy terms in simple language
- Follow up with the insurer on your behalf
- Help you understand what is payable
- Escalate if a claim seems unreasonably delayed
- Support you emotionally during a difficult period
But agents cannot:
- Approve or reject claims
- Influence medical underwriting decisions
- Speed up investigations beyond the insurer’s internal process
- Force the insurer to meet customers
Understanding this makes the entire relationship smoother for everyone involved.
7. When You Should Escalate to FMOS
If your claim is officially rejected and you believe the decision is unfair, you can escalate the case to Financial Markets Ombudsman Services (FMOS).
Important notes:
- FMOS only handles disputes after a formal rejection
- “Under review” or “pending additional documents” cases cannot be escalated
- FMOS decisions are independent and free
This gives customers an additional layer of protection.
8. Why Choosing a Good Agent Still Matters — A Lot
Even if agents have no formal authority in claims decisions, a good agent can make the entire experience far less stressful.
A good agent:
- Responds quickly when you’re hospitalised
- Guides your family when you’re too weak to handle documents
- Explains what the insurer is checking and why
- Helps manage expectations truthfully
- Ensures your policy was properly set up from day one
- Advises you on the right tier, deductible level, and hospital coverage
The truth is simple:
The value of an insurance agent is not measured when you buy a policy — it is measured when you fall sick.
Final Thoughts
The claims process in Malaysia is more structured, technical, and regulated than most people realise. Agents play a supportive but informal role, insurers manage decisions internally, and customers often struggle because they are navigating unfamiliar territory during the hardest moments of their lives.
A good medical card, properly chosen and well-managed, can make all the difference. And having an agent who is transparent, reachable, and committed to your wellbeing is still one of the strongest forms of support you can have.
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