Written by Mei Ling
Published 16 October 2026 | Last updated -
Who we are: Home Care Apps Team
Quick answer: Hospital insurance claims in Malaysia are rejected, reduced or delayed for five avoidable reasons: not checking cover and exclusions, incomplete health disclosure, skipping pre-approval, missing documents, and late submission with no follow-up. Avoiding them is no promise of approval, because the insurer decides each claim. Facts checked October 2026.
Key points
- Industry data as of 2025 shows over 90% of claims approved.
- LIAM names non-disclosure and general exclusions as top decline reasons.
- Missing documents can delay a claim, so send the full set.
- If rejected, ask why, appeal to the insurer, then FMOS or BNMLINK.
Why do hospital insurance claims get rejected in Malaysia?
Most claims are approved, and the main health insurance claim rejection reasons are policy rules and disclosure. Deputy Finance Minister Liew Chin Tong told the Dewan Rakyat on 6 July 2026 that industry data as of 2025 showed an average claim approval rate of over 90 per cent (Malay Mail). The Life Insurance Association of Malaysia (LIAM) chief executive, Mark O'Dell, told The Star: "The biggest reasons for decline were non-disclosure of pre-existing conditions or general exclusions" (The Star, 24 May 2026).
The Financial Markets Ombudsman Service (FMOS) lists policy exclusions, breach of terms and conditions, and non-disclosure among its most common causes (FMOS content in Malaysiakini, 22 July 2026). A claim can also be paid in part, because deductibles, co-insurance and room limits reduce what the insurer pays. The five mistakes below follow these causes. Fixing them is no promise of approval.
1. Not checking your cover, exclusions and limits first
Ask your insurer what your policy covers before planned treatment, because exclusions, waiting periods and limits decide many outcomes. The BNM MediAsas pilot FAQ lists 35 exclusions, including pre-existing conditions and items not directly related to treatment, such as television rental (B16). It sets a 30-day waiting period for most conditions and 120 days for specified illnesses (C10). Payment can also be reduced: at an out-of-network hospital the Teras plan adds 20% co-insurance, capped at RM3,000 per disability (B2), and a voluntary room upgrade is reimbursed only up to the sharing-room rate (B12) (BNM FAQ).
Fix: read your policy wording and Product Disclosure Sheet, and ask in writing whether this treatment and hospital are covered. Insurers have duties too: BNM told CodeBlue in December 2025 that exclusions "not made known to the policyholder" cannot be enforced (CodeBlue). See our 10 questions to ask your insurer.
2. Giving incomplete health information when you apply
Declare your full health history when you apply, because non-disclosure is one of the two biggest reasons for decline. The BNM pilot FAQ says failing to declare accurately and completely "could result in claims being delayed or rejected" (C6), and a pre-existing condition includes one you "reasonably should have been aware of" (C4). FMOS says a symptom people dismiss as minor, such as a recurring cough, "may still be material to the insurer's risk assessment", and a condition not disclosed "even by mistake" could affect a claim and cover.
After seven continuous years, MediAsas claims cannot generally be contested for non-disclosure, except for fraudulent, deliberate or reckless cases and certain pre-defined conditions (C5). Bank Negara is considering a "no look back" policy for conditions unintentionally not disclosed, but on 6 July 2026 The Star reported it was still under consideration (The Star).
Fix: write down your treatment history with dates, answer every question, and never leave something out.
3. Skipping pre-approval or other policy conditions
For a planned admission, ask the hospital's insurance desk to request pre-authorisation, because FMOS says a claim for a non-emergency elective procedure "may not be covered" if prior approval or a guarantee letter was "required but not obtained" (FMOS content in Malaysiakini). Under the MediAsas pilot, a guarantee letter is requested through a Preferred In-Network provider and approval is subject to assessment (C14, C15). If none is issued, you may still be treated and claim on a pay-and-claim basis under the policy terms (C16).
LIAM's chief executive also told The Star that 94% of initial and 97% of final guarantee letters were approved; the article gives no period.
Fix: keep every guarantee letter, check the final one before discharge, and read your policy for notice rules. See what a guarantee letter is.
4. Sending incomplete or unclear claim documents
Send the full set at once, because missing documents delay a claim. The BNM FAQ says claims processing "may be delayed until all required documents are submitted" (C20), and Great Eastern Life says "incomplete submissions are often the reason for delays". The Financial Education Network (FEN) tips reported by Malay Mail advise having the doctor fill in and sign the claim form, and keeping itemised, dated receipts (Malay Mail, 15 February 2026).
Fix: use a checklist: claim form, original itemised bills and receipts, discharge summary or medical report, ID and bank details. Our guide lists the documents needed to claim. If you use home nursing after discharge, ask for itemised invoices and visit records; Home Care Apps says it provides a detailed post-visit clinical report that can be submitted for reimbursement claims, but your insurer decides what it accepts.
5. Submitting late and not following up
Submit as soon as your papers are ready and track the claim, because many policies set a time limit. Great Eastern Life says "most insurance policies include a timeframe for submitting claims", and the exact window depends on your policy. The BNM pilot FAQ gives none, and Prudential BSN Takaful asks claimants to inform it of a claim "within the required timeframe". The BNM FAQ says you can view claim status through the insurer's official channels once the claim is submitted (C19).
Fix: note the date you submit, ask for a reference number, check the status regularly, and answer any request for more information quickly.
How do I appeal a rejected or reduced insurance claim?
Ask the insurer for the reason in writing, appeal to the insurer, and only then go to FMOS or BNMLINK. The BNM FAQ says you may appeal with supporting documents, and the review may include FMOS or BNMLINK (C22). Insurance agents quoted by The Star advise requesting a detailed breakdown of why the claim was rejected, then gathering supporting documents and, if needed, a letter from your doctor.
| Step | Who | What to know |
|---|---|---|
| 1. Ask why | Insurer or agent | Ask for the reason and the policy clause |
| 2. Appeal | Insurer's complaints unit | Send supporting documents and, if needed, a doctor's letter |
| 3. FMOS | Financial Markets Ombudsman Service | Free; file within 6 months of the insurer's final decision, or if it has not replied in 60 days; claims up to RM250,000 |
| 4. BNMLINK | Bank Negara Malaysia | Not open to cases not first referred to the insurer's complaints unit, or already with FMOS or the courts |
FMOS terms: FMOS and its 2025 brochure. BNMLINK is open 9:00 a.m. to 5:00 p.m., Monday to Friday, excluding public holidays (BNM).
What to do next
- Ask your insurer in writing what this treatment and hospital cover.
- Answer every health question fully and honestly when you apply.
- Ask the hospital's insurance desk about a guarantee letter before a planned admission.
- Keep a document checklist, and note the date you submit.
- If a claim is rejected, ask for the reason in writing, then appeal.
FAQ
Why do insurance claims get rejected in Malaysia?
LIAM's chief executive says the biggest reasons for decline are non-disclosure of pre-existing conditions and general exclusions. FMOS also lists breach of terms and conditions. Industry data as of 2025 shows an average approval rate of over 90 per cent.
What documents delay a claim?
The BNM pilot FAQ says processing may be delayed until all required documents are submitted (C20). Great Eastern Life says incomplete submissions are often the reason for delays. Use our claim documents checklist.
Is there a deadline to submit a claim?
The BNM pilot FAQ gives none. Great Eastern Life says most policies include a timeframe, and Prudential BSN Takaful asks claimants to inform it within the required timeframe. Read your policy and submit early.
Can I ask the insurer why my claim was rejected?
Yes, and it is a sensible first step. Insurance agents quoted by The Star advise requesting a detailed breakdown of why a claim was rejected. You can then appeal to the insurer's complaints unit.
How we can help
Home Care Apps arranges registered nurse home visits across Peninsular Malaysia, subject to nurse availability in your area. We do not handle insurance claims or give insurance advice, and we cannot guarantee any claim. If you use home nursing after discharge, we can explain what a visit includes and what it costs, in writing: send an enquiry or try the free care assessment.
Sources
- Bank Negara Malaysia, MediAsas Frequently Asked Questions, Version 1: Pilot Programme, 29 July 2026. PDF. Items B2, B12, B16, C4 to C6, C10, C14 to C16, C19, C20, C22.
- Bank Negara Malaysia, Medical and Health Insurance/Takaful (MediAsas). bnm.gov.my/mhit, page read 16 October 2026 (checked for a newer FAQ: none shown).
- The Star, "When coverage runs thin", 24 May 2026 (LIAM chief executive Mark O'Dell on reasons for decline and guarantee letter approval). Link.
- Malay Mail, report on the Deputy Finance Minister's reply on the claim approval rate, 6 July 2026. Link.
- The Star, "Bank Negara mulls 'no look back' policy for medical insurance claims, Parliament told", 6 July 2026. Link.
- Malaysiakini, "Why insurance and takaful claims get rejected: The most common reasons we see at FMOS" (content provided by FMOS), 22 July 2026. Link.
- Financial Markets Ombudsman Service, website, page read 16 October 2026 (page metadata modified 24 September 2026). fmos.org.my.
- Financial Markets Ombudsman Service, FMOS Brochure (English), 2025, as hosted by Hong Leong Assurance. PDF.
- Malay Mail, "First time making insurance claims for your hospital stay? Here are some tips", 15 February 2026 (tips from the Financial Education Network). Link.
- CodeBlue, "BNM Tells Insurers To Settle Medical Claims Promptly, Prohibits Applying Unknown Exclusions", 22 December 2025. Link.
- Great Eastern Life Assurance (Malaysia) Berhad, How to make a medical claim in Malaysia (Greatpedia), undated (footer 2026), page read 16 October 2026. Link.
- Prudential BSN Takaful Berhad, Claims Made Easy, page read 16 October 2026. Link.
- Bank Negara Malaysia, BNMLINK contact page, undated, page read 16 October 2026. Link.
- Home Care Apps, services page, read 16 October 2026. homecareapps.com/services.
Note
This is general information, not medical, financial or legal advice, and Home Care Apps is a home nursing provider, not an insurer, takaful operator or insurance agent.