Case 1: Medical claim declined - Outpatient treatment only - Does not fall within the Certificate coverage which requires admission.
The Participant’s medical claim was repudiated by the Takaful Operator on the ground that the treatment sought was an ‘out-patient’ treatment and that there was no admission to the hospital. As such, the claim does not fall within the Certificate coverage.
Investigation and Findings
The Takaful Operator’s decision was based on the medical note from Hospital ABC which indicated that the participant had ‘CT coronary angiogram’ procedure on 19 January 2016 as an ‘out-patient’ treatment.
The Takaful Operator’s decision was also based on the terms and conditions of the Certificate which stated the following:
“2. Description of benefit
“2.1 Subject to the general condition and the terms specified in this contract ... while the Certificate is inforce upon receiving satisfactory proof that the Participant is confined to a hospital for medically necessary services, and/or treatment due to illness or injury...., we will pay the eligible expenses for the benefit covered...”
The Certificate defined “day surgery” and “hospitalisation” as follows:
(e) Day surgery means a patient who needs the use of a recovery facility for a surgical procedure on a pre-planned basis at the hospital/specialist clinic.
(j) Hospitalisation means admission to a hospital as a registered in-patient for medically necessary treatments for covered disability upon recommendation of a physician.
In addition, the Certificate defined “out-patient” as follows:
(p) Out-patient means the Participant is receiving medical care or treatment without being hospitalised and includes treatment in a day care centre.”
Based on the supporting documents submitted, the Case Manager noted the following:
- the Participant had sought treatment for “coronary artery disease”.However,the procedure done, i.e. CT coronary angiogram was administered as an out-patient treatment.
- the Participant was not admitted in hospital or been hospitalised. Her condition does not require her to be admitted or confined in a hospital.
- the Certificate covers “out–patient treatment”. However, it is only limited and confined to “emergency accidental out-patient treatment”, “out-patient kidney dialysis treatment” and “out-patient cancer treatment”.
The benefit under the Certificate is only payable to the Participant if he or she is confined to a hospital by reason of illness or injury.
The Participant is also not entitled to claim for “pre-hospitalization consultation benefit” or “post-hospitalization treatment benefit” as the benefits are only payable if the participant was hospitalised.
Based on the above, the Case Manager was of the view that the decision of the Takaful Operator was in accordance with the terms and conditions of the Certificate. The Case Manager recommended that the decision of the Takaful Operator to repudiate the Participant’s claim be affirmed.
The Participant decided not to refer her dispute to the Ombudsman for adjudication although she was given 30 days to do so.