GMC Being Reactivated To Address Delays In GL issuance, Treatment Payments  

KUALA LUMPUR, Nov 6 (Bernama) — The government, together with Bank Negara Malaysia (BNM) and stakeholders from the medical, hospital, insurance and takaful operator (ITO) industries, are reactivating the Grievance Mechanism Committee (GMC), said Deputy Finance Minister Lim Hui Ying.  

She said the committee is being revived to address delays in the issuance of guarantee letters and disputes over treatment payments under Medical and Health Insurance/Takaful (MHIT) policies.  

“The committee serves as an industry platform to tackle operational and business practice issues such as harmonising procedures to reduce delays in issuing guarantee letters and reviewing cases involving disputes over payments for treatments covered under MHIT policies.  

“Based on discussions, the GMC may issue guidelines for payers, medical practitioners and healthcare providers as a reference for similar cases in the future,” she said during the oral question-and-answer session in the Dewan Rakyat today.  

She was responding to a supplementary question from Sim Tze Tzin (PH–Bayan Baru) regarding the framework adopted by the government to ensure that MHIT premium adjustments are reasonable and in favour of the people, as well as the roles of third-party administrators (TPA) and the GMC in coordinating between medical practitioners and insurers.

Lim said the government takes note of the issue raised — generally, the challenge of medical cost inflation is complex and requires a “whole-of-nation” approach.  

“Long-term reforms are essential to address the root causes of medical inflation and to ensure that the private healthcare protection system remains resilient and inclusive,” she said.  

On the role of TPAs, Lim said insurers and takaful operators have the responsibility towards policyholders to review and manage claims according to the terms of the contract, including verifying that claims fall within the scope of procedures covered by the policy and are medically necessary.  

“This review is conducted solely to confirm what is covered and claimable based on commonly accepted treatment protocols and clinical practice guidelines, including those issued by the Ministry of Health ,” she said.  

According to Lim, in cases where treatment does not follow standard clinical protocols, ITOs will conduct further review to understand the clinical reasons for such treatment.

“If the treatment is found to be medically necessary, the claim must be paid. This is crucial to control medical claims inflation resulting from wastage and abuse, which, if left unchecked, could lead to unreasonable premium hikes and negatively impact all policyholders,” she said.  

She added that ITOs and TPAs have no authority to determine patient care, as that responsibility remains exclusively with doctors.  

“If the recommended treatment is not covered under the insurance policy, payment may be settled directly by the patient,” she said, adding that industry data shows ITOs have maintained an average claims approval rate exceeding 90 per cent. 

— BERNAMA