Dear Sir / Madam,
In reference to the joint press statement by LIAM, PIAM and MTA on 17th January 2021:
"Generally, pandemic-related risks are not covered under any insurance and takaful plans worldwide. The exclusion stems from the difficulty in pricing for coverage relating to an event like a pandemic that may occur once in a lifetime, having an incalculable impact and cost. COVID-19 is a pandemic hence it is not insured/covered under Medical and Health insurance/takaful benefits."
We wish to clarify during our early stage of the pandemic, we had, on goodwill basis, waived the exclusion clause (any communicable diseases requiring/required quarantine by law) on Covid-19 for our customers who are treated at designated government hospitals in Malaysia. Hence these waivers do not apply to hospitalization involving private hospitals for medical plans with the mentioned exclusion clause. For medical plans that do not carry this exclusion clause, treatment cost can only be on reimbursement basis (HAS facility is not available), subject to reasonable & customary charges.
Therefore, in this difficult time of pandemic and ambiguity around it, we urge all panel hospitals to adhere strictly to our HAS Procedures to avoid any miscommunication or mishandling of cases. Below are some reminders on HAS Procedures and points to pay attention:
For HAS Admission Procedure, as per our memo dated 20th Jan 2021, panel hospitals are required to submit any available Covid-19 test result during Pre-Authorisation Letter request together with all other relevant documents within 24 hours from the time of the admission of the Person Covered.
For Top Up Procedures, please submit Top-Up request with interim itemized bill(s) when:
- The amount incurred has reach the maximum amount in our Pre-Authorization Letter / Top Up stated amount
- The length of stay reaches the 3rd day of admission
- Any change of diagnosis
- Any change of treatment plan (e.g. additional procedure)
- Any latest Covid-19 test result (e.g. second test result or test result was not available during Admission Procedure)
- Any latest diagnostic/laboratory/investigation reports
For Discharge Procedures, hospital is required to try best to submit discharge request at the shortest time when Person Covered is discharging. Please take note on the below points:
- Doctor/Specialist(s) is strongly encouraged to list out the detailed description for all the procedures with further elaborations on the reasons of performing at Part 2 form to avoid any charges to fall under Claim Under Review (CUR), also include MMA/PHFSA code
- A detailed breakdown of all the Charges (please elaborate in detail for items that do not have clear description or that are charged in package).
- Any latest Covid-19 test result (e.g. second test result or test result was not available during Admission/Top Up Procedure)
- Any latest diagnostic/laboratory/investigation reports
We have also attached FAQ relating to PruBSN practice on Covid-19 on this memorandum.
Kindly inform all relevant departments (business office, front office, patient administration, Accident & Emergency Department, admission & discharge counter, insurance counter, finance & billing department etc.)
Thank you for your understanding and cooperation.
FAQ: Covid-19 Medical Coverage for PruBSN Customers
- Is HAS facility available for PruBSN Customers hospitalized for Covid-19 treatment at private panel hospital?
Covid-19 related admissions are not available via the HAS (cashless) facility. For products where there is no exclusion, customers can apply under reimbursement and will be reviewed upon claim submission.
- Can PruBSN customers "pay & file" for Covid-19 admissions at private hospital?
For medical plans with the exclusion, treatment of Covid-19 in private hospitals will not be covered. For medical plans that do not carry the exclusion, treatment cost will be on reimbursement basis, subject to Terms & Conditions (T&C) of the certificate, including but not limited to medically necessary and reasonable & customary charges.
- How would PruBSN customers know whether their medical plan is with or without the exclusion clause for Covid-19?
PruBSN HAS will call both agent and customer to explain the reject reasons and guide them on the next steps accordingly. Alternatively, PruBSN customer can also contact their agent or our Customer Care hotline (03-2053 7188) for enquiry.
- Does PruBSN cover cost of Covid-19 test required before essential surgery/procedure?
PruBSN does not cover Covid-19 tests charges done for:
Screening purposes:
Though many hospitals mandates that all emergency surgical procedures are required to be screened for Covid-19 and some hospitals perform Covid-19 test across the board to all patients admitted, please be informed that it is still deemed as a screening purpose and falls under certificate exclusion.
Medically not necessary:
Diagnosis not in relation to the necessity of Covid-19 test being done. E.g. Diagnosed with Ankle sprain and Covid-19 test done, PruBSN will not provide coverage for the test not related to diagnosis as it is also deemed as a screening purpose and falls under certificate exclusion.
- Can PruBSN customer appeals for declined Covid-19 test coverage in Question 4?
The decisions on Question 4 non-coverage are final, however PruBSN customers can submit claim via My Covid Test Fund at www.MyCTF.my, subject to funds availability and Terms and Conditions (T&C).
- Is the use of the recommended personal protective equipment (PPE) by MOH during a surgery/procedure such as N95 mask, isolation gown, gloves and eye protection (goggles/shield) fully covered under our certificates??
Coverage is subject to our certificate’s Terms & Conditions (T&C), and also as described at Question 4. For products where there is no exclusion, customers can apply under reimbursement and will be reviewed upon claim submission.
- Is PruBSN customers hospitalized for Covid-19 treatment at private hospital eligible for Covid-19 Cash Relief under Special Covid-19 Coverage 2021?
No, Covid-19 Cash Relief under Special Covid-19 Coverage 2021 is only payable upon hospitalization and where active treatment is provided at designated government hospitals, as per listed at http://covid-19.moh.gov.my/garis-panduan/garis-panduan-kkm
