Terms and Condition of medical and health insurance

The medical & health insurance (MHI) policy is a legal contract, and the meanings used in the policy will apply when a claim is made. That is why it is important that you read and understand the terms used in a MHI policy. If you still do not understand them fully, ask your insurance agent or company to explain them to you.

Your policy contract will have the actual definitions for the terms used in the contract. They generally will be the legal meanings, so you have to read and understand them carefully. Ask your insurance agent or company what they mean, if you do not understand them fully.

The following list is some of the more important terms used, but are not the legal definitions used in your contract. You may refer to your policy contract for the actual definition:

Pre-existing conditions

These refer to conditions or illnesses that existed before the effective date of a MHI policy, for which you are receiving treatment or have shown symptoms. It does not matter whether you were aware of them or not. If you consulted a medical doctor for any pain or discomfort in connection with the condition, it would be regarded as a symptom of a disability.

Co-payment

If you are hospitalised and the board rate is higher than your eligibility, you will bear the difference in the room charges as well as some portion (usually between 10% - 20%) of the other eligible benefits described in the policy contract.

Qualifying/waiting period

Most MHI policies contain a waiting period for illness and disease, which means that eligibility for benefits under the policy will only start 30 days after the effective date of the policy.

Free-look period

If you decide not to take up a MHI policy, you can cancel the policy by returning it to the insurance company within 15 days from the date of issue. You will be entitled to a refund of the full premium, after deducting administrative expenses incurred by the insurance company for issuing the policy. These expenses shall be RM50 or 10% of the gross premium paid, whichever is lesser.

Overseas treatment

You may or may not be covered for treatment obtained overseas, subject to the exclusions, limitations and conditions specified in the policy contract.

Misstatement of age

Your age is an important rating factor in your MHI policy. If you have misstated your age and the premium paid as a result is not enough, any claim payable under the policy will be pro-rated, based on the ratio of the actual premium paid to the correct premium that should have been charged.

That means you will only receive part of your claims, instead of the total amount incurred.

Residence overseas

If you were to live or travel out of Malaysia for more than 90 consecutive days, no benefits will be payable for medical treatment outside Malaysia