Dear All old Prudential plan owner!! Beware!

im surprise when i admitting for government hospital (PPUM) for day surgery (RAI 131) .Prudential customer line: 03-2116 0228

Upon checking my insurance policy, She CONFIRMED with me that OUTPATIENT TREATMENT/DAY SURGERY is not COVERED/CLAIMABLE unless Accident by my cashless insurance card.

PRUflexi MED since 2012. 7 Years old medical card!

Upon my questioning on agent, they say only NEW plan cover day surgery and outpatient treatment. You will need to go private hospital and try to do full admission.

I Checked back my policy book and it written clearly OUTPATIENT TREATMENT is cover. Currently im paying all the Private hospital bill myself up to 2k+ so far and lucky hospital didnt take alot deposit since they know im disputing with insurance now. Until NOW im not sure its Claimable OR NOT.

https://www.prudential.com.my/en/our-servic...rgery-benefits/

So this is the scenario that will happen in future.. you got sudden stroke or chest pain or faint and send by ambulance to hospital government or private..after done some minor surgery, medicine and you can back home the same day or you choose for for so call outpatient /day surgery..

YOUR OLD PRUDENTIAL MEDICAL CARD WONT BE ABLE TO CLAIM IT/ ADMISSION with the card and its not COVERED cause its NOT ACCIDENT

PRUFLEXI MED plan. please double check with your agent or simply call to the customer line. AGENT will Mentioned New plan is covered and who didnt update it... eat yourself..






This post has been edited by max880930: Feb 28 2019, 12:31 AM

What Can You Do Should Your Insurance Claims Get Rejected

https://www.ibanding.com/insurance-claims-get-rejected/

https://www.google.com/search?source=hp&ei=...131.DUYjXBYGFDI

Most disputes involve insurance claims — OFS
http://www.theedgemarkets.com/article/most...-claims-—-ofs

hope these things never ever happens to me or my family members.....else


This post has been edited by MUM: Feb 28 2019, 12:43 AM

I can say of all insurance claims my patients try to get. Prudential is the hardest to get

I agree on this.

They practise prudence in giving out money?

Let me try to help you resolve this issue.

If you had been admitted to the PPUM (not as Day Surgery since there isn't any surgery being performed), you can submit the following for claims consideration:-

1. The original PPUM Bills & any tests/reports done
2. The Claim Form (Doc ID 11601067)
3. The Doctor's Statement (DocID 11601007) - to be filled up by the PPUM Dr that treated you

Item 2 & 3 can be obtained from your agent or Prudential website. Before submitting the claim, please make a scan copy for future references.

Item 3 is required because PPUM is not a panel hospital for Prudential, therefore a GL is unable to be issued.

Whether it is an old or new medical card, it does cover DAY SURGERY. However, it is required for a surgery to be performed and in your case there isn't any surgery. Therefore it is not claimable under day surgery. Since there is an admission to PPUM, you may proceed to submit the claim as mentioned above.

A list of Day surgery procedure can be downloaded <<Here>>

The "Day Surgery" was introduced as it DRASTICALLY REDUCES the medical claim BILL as most cases there is no need to be admitted to hospital, eg, Cataract Surgery.

QUOTE

Example
1. If a person go see the Dr and the Dr prescribe High Blood Pressure pill, there wasn't any admission, the cost have to be paid by yourself. However, do keep the bill. It can be claimable if there is admission (for the PruFlexi Med the Pre Hospitalization is 90 days) later. Pre & Post Hospitalization IS OUTPATIENT TREATMENT.

2. However, if a person have breathing complication/extreme nausea/fainting, admitted and does angiogram, then it is covered. Any medication given by the Dr that addresses to the problem, will be covered. If the Dr prescribe you Vitamin, naturally, it will not be covered.

3. Once discharge there is another 90 days of Post Hospitalization (which is to be done as OUTPATIENT), pay and claim.

Ps. I also have client who has hyperthyroid, initial RAI meds (which is not covered) and after a month, opted for surgery as it was getting bigger and painful. Surgery done was covered together with the earlier pre-hospitalization.

This post has been edited by roystevenung: Feb 28 2019, 11:25 AM

Hi Sifu, is eye cataract surgery cover under prud med insurance.
Tia

spot on..
they try to give excuses to pay

Yes, including the lenses, subject to the limit of the "Intraocular Lens Benefit" (for newer plans it is limited to Rm6k)

Previous plans there wasnt a cap, which was abused. Seen Rm12k for cataract bill.

I had personally made plenty of claims against Prudential for my late mother on the following basis :-
- pay first using your own cash / credit card.
- claim later.

Item that can be claim under policy will subsequently be reimbursed. Item that are not allowed will be omitted from the disbursement.

I suspect in TS case it is some how related to PPUM is trying to get clearance from Prudential, where as in Prudential point of view, there are some grey area on day surgery where some case / item / certain policy (old or new) is allowed, and some is not allowed to claim. Hence Prudential is not endorsing the claim on the spot against the hospital request for clearance.

I hope that TS will update subsequently what happen if he made a claim, and whether it is agreeable outcome on the claim or otherwise.

In my humble opinion, there is no guarantee that your medical card / policy will grant you hospitalisation / surgery and what not.
The surest way is still cold hard cash or a credit card with a big enough credit line to cover for the cost of estimated medical fees.

Another note on the pay first and claim later, the staffs in the (in my case private) hospital openly admitted that it is cheaper to do so as hospital bump up the fees if it is claiming against insurance.
Hence this may have some relevance for policy with life time claim limit.

checked with Optimax, around 23K for cataract.

Check with the panel hospitals pls

Will do, Thx

Thanks for your long details which alot prudential agent arent well trained in all this anyway. What happen on that day was Agent and I called Customer service, even agent confirmed our old plan doesnt cover any day surgery Or outpatient treatment due to any illness even you fainted unless accident.

As i say, i RECORDED the full calling to customer service and they confirmed MANY times ANY outpatient/day surgery is not cover for our old plan. Pruflexi med

RAI 131 Is consider as radiotherapy which can be opt for day surgery.
Radioactive iodine treatment is a type of internal radiotherapy. The treatment uses a radioactive form of iodine called iodine 131 (I-131).



STILL, Alot agent Assume that Day surgery is cover for old plan and didnt INFORM THEIR CUSTOMER TO CHANGE TO NEW PLAN immediately which CAUSING WHAT HAPPEN AS NOW.

IF ITS COVER,WHATS THE POINT IM SPENDING MONEY FOR ADMISSION UNKNOWN CLAIMABLE OR NOT. LUCKY THAT I HAVE SOME CASH.

PAY AND CLAIM WITH UNKNOWN ITS CLAIMABLE OR NOT CAUSE THEY CONFIRMED NOT COVER. IF YOU ARE ADMITTED TO GOVERNMENT HOSPITAL DUE TO EMERGENCY AND PRUDENTIAL WILL SAY SORRY GOVERNMENT IS NOT PANEL, PLEASE TRANSFER TO OTHERS HOSPITAL. IF YOU CHOOSE TO DO AT GOVERNMENT HOSPITAL CAUSE URGENT DEADLY..PAY YOURSELF AND CLAIM LATER FOR THAT 20K+...ROFL..

Can you confirm to us here GOVERNMENT hospital is cover or not? i called the hotline they say not cover.. so if accident or emergency..die die must go panel hospital...if not pay yourself ..


Attachment is private wing for um hospital..prudential is not in although almost all insurance company is there.. Beware prudential owner..




This post has been edited by max880930: Mar 1 2019, 04:26 AM

This is the problem in insurance nowadays, which we consumer think its covered and pay for years only to discover this and that not covered, which somehow i felt we consumer is a fool.

Is there a way to check our policy coverage in layman term rather that so many fine prints with t&c?

This post has been edited by arthurlwf: Mar 1 2019, 06:25 AM

I can confirm to you that Day Surgery benefit is applicable to ALL Prudential medical card (irrespective of old or new). As mentioned earlier, the reason for the insurer to have the Day Surgery Benefit is to cut the cost of having minor admission.

I believe the Customer Service has misunderstood on your request and for that I do apologise as they are not directly involved in the claims process. There are a lot of things not made known to the Customer Service especially when it comes to claims

For example the cataract surgery, before the introduction of the Day Surgery Benefit, the client will still need to be admitted for 1 day even though it is not required. This incur room charges of 1 day, which translates to extra cost to the insurer.

For your information, the Day Surgery Benefit is a PRE-PLANNED, non emergency day surgical procedure with the ISSUANCE of Guarantee Letter.

This has to be applied 7 days before the intended surgery. The benefit of this is that the client do not need to wait for the issuance of the Guarantee Letter. This means that it has to be requested by a Panel Hospital, but unfortunately in your case, PPUM is not under a panel hospital.

Since you had been admitted to the PPUM, for the PPUM claims, my advice is to get the Dr to write the Doctor’s Report as stated in my previous reply.

I believe the confusion is due to Customer Service and how Day Surgery works. In your case for PPUM, you should claim under normal admission, not under day surgery.

May I concur that you were not informed by your agent that if you were admitted to a non-panel hospital, you need to pay and file a claim later? If that is the case, at least you may feed back to your agent for his/her improvement.

Yes it is a known fact that if you are admitted to a non-panel, it is on reimbursemnent basis aka, PAY AND CLAIM, irrespective of ANY INSURER.

If you are overseas on a holiday, unless it is accidental, you will also need to pay and claim and the reimbursement will be customary to what is being charged in a hospital in Malaysia. For eg, dengue at Singapore, cost SGD 8K, of which you will only be reimbursed RM10K.

There are many reasons why some hospitals are not a panel for the insurer as there are lots of criteria to qualify to be a panel. The Medical Insurance is a MULTI-MILLION ringgit business and for us to qualify the hospital, it has to be of certain standards, from the equipments, specialist, facilities, billings, comformance of standards and many more.

The medical reports/test & billing details must be made available to the insurer when a person is admitted to the hospital. Some of the doctor reports can only be given after 2 months, in which directly translates to delay in paying the claims to the customer.

FYI the PruFlexi Med will reimburse the room differences back to the customer, eg, if your room is RM200, and you stayed in a RM150 room, Prudential will reimburse RM50/day once you are discharged from the panel hospital. The fastest reimbursement that I had seen is 5 working days upon discharge. Of course all these are with facts and proof, not simply bla at an open forum

See above on the process for getting treatment at a non-panel hospital.

This post has been edited by roystevenung: Mar 1 2019, 09:40 AM

You are right to the Point. PRUDENTIAL CUSTOMER SERVICE IS NOT PROFESSIONAL OR should i say what they say cannot be trusted which MISLEAD US that Day surgery, Outpatient treatment is not cover AND THEY WAN US TO PAY FIRST And Claim later i called at least 3 times and they saying the same thing everyone of them. Its doesnt matter its government hospital or private, ITS NOT COVER! SO DO NOT DO Day surgery or outpatient treatment.

I had admitted to PPUM and upon confirmation ON outpatient treatment is NOT COVER i Immediately TRANSFER OUT to PANEL HOSPITAL SUNWAY. and upon arrival there, prudential say the bloodly hell same thing that outpatient treatment is NOT COVER and yes i WILL do FULL Admission and GONNA STAY TWO WEEKS IN PRIVATE HOSPITAL by Spending PRUDENTIAL CUSTOMER MONEY SINCE PRUDENTIAL REJECTED MY OUTPATIENT TREATMENT

UNTIL NOW, IM PAYING MY OWN MONEY FOR THE ADMISSION/DOCTOR VISIT and WAITING TO SEE WHAT DRAMA THIS PRUDENTIAL WILL DO upon my discharge.

IF Customer Service cannot be trusted on what they say and AGENT say its NO COVER also and this PRUflexi med cannot be used for day surgery/outpatient treatment in the END STILL WE ARE THE ONE THAT PAYING IT. Im doing Pre-admission for full surgery instead of DAY SURGERY now since they rejected it.

How many people have prudential FOOLED? i heard prudential is not paying hospital thats why they are not listed/banned as panel. Prudential even put some ambassador at certain private hospital BUT THEY CONFIRMED ME That OLD PLAN PRUflexi med IS NOT COVER HAHA.. and here someone agent still telling me that its cover..

Maybe you can show me which day surgery listing that mention PRUflexi med cover... the new plan have it, old plan dont have. The link you give is only applicable for new plan even they dont mention which plan have it. PRudential AMBASSADOR at hospital do pass me that and mention its for new plan only. Maybe a PRUDENTIAL letter with title head will be sufficient. I Requested for that letter before and refused also. PROVE TO US HERE

If you did get admitted to PPUM due to the thyroid issue, then of course you can claim, even though it is a pay and claim process.

However, if you did not get admitted to PPUM, then of course its not claimable as it is considered as consultation only.

Same goes to if you go see a Dr for fever, and the Dr prescribe to you meds, with no admission, is it claimable from your medical card? No you can’t.

Since you had registered for admission to a panel hospital, if the case is coverable, you may also submit the PPUM bill for claims later as it is considered as Pre Hospitalisation bill (90 days before admisssion).

If the case is coverable, those bills can be submitted for claims after your last follow up.

The Day Surgery Benefit (DSB) works only at Panel Hospital as mentioned in the earlier post and it is stated in your policy (of which you had also posted in the first post) document. The list of DSBs are available on the Prudential Website.

From where/whom did you hear that Prudential is not paying the hospitals? Please enlightened me so that I may feedback to Prudential. Thanks

Lets not divert from the MAIN ISSUES here on DAY SURGERY AND OUTPATIENT TREATMENT

***Maybe you can show me which day surgery listing that mention PRUflexi med cover... the new plan have it, old plan dont have. The link you give is only applicable for new plan even they dont mention which plan have it. PRudential AMBASSADOR at hospital do pass me that and mention its for new plan only. Maybe a PRUDENTIAL letter with title head will be sufficient. I Requested for that letter before and refused also. PROVE TO US HERE***

i know how medical card works as i used ING cashless admission before for day surgery many years back before using prudential. im super regretting/disappointing now to choose prudential.

NOW I know whats PAY AND CLAIM Later which prudential card is CASHLESS card with panel works!? IF Prudential HOTLINE and AGENT had said its not cover then its not CLAIMABLE.... and AGENT WILL SAY WE WILL TRY TO CLAIM IT SOOOoooo PAY YOURSELF FIRST and take your OWN RISK WHICH IS WHY PRUDENTIAL ARE PISSING your 7 years customer here!

Oh yah, regarding the policy book details its me that dig it up and argue with prudential them AND STILL THEY CONFIRMED ITS NOT COVER DAY SURGERY/OUTpatient treatment. so that policy book is RUBBISH. im tired to argue with them for 3 days already so i recorded all the details including agent as PROVE including Whatsapp. SO DONT KEEP DIVERTING ISSUES.

IF You wanna help your company,PRUDENTIAL, SHOW US your customer for 7 years LETTER that confirm OLD PRUFLEXI MED card COVER DAY SURGERY AND OUTPATIENT TREATMENT. This will help CLEAR people DOUBT ON PRUDENTIAL. IF YOU cant confirm this with LETTER, IT PROVE YOU CANT EVEN CONFIRM TO YOUR PRUDENTIAL CUSTOMER with this same plan PRUFLEXI MED. and will ask them pay first lolz...

This post has been edited by max880930: Mar 2 2019, 03:29 AM

If you haven't noticed, I am trying to help you resolve this issue. It would be better to find solution to the problem rather than hyping on it, don't you agree?

I am not diverting the main issue and I am still saying that Day Surgery is covered in PruFlexi Med as mentioned in the policy book and it is even mentioned in the brochure. For your information, any official letter by Prudential can only be issued by HQ, therefore if you insist on it, you need to take that to HQ.

Point is, if you go see the Dr and he admit you with Guarantee Letter (GL) -> normal hospitalization with GL admission is required if the case is cover able by checking the Exclusions.

However, if it is a non-emergency cases and can be done as a Day Surgery, the Dr will still need to apply for the Guarantee Letter 7 days prior to the day surgery. Between the date of the surgery, Prudential will also check whether the case is cover able based on the Exclusions of the policy, pre-existing, hereditary, congenital etc.

If the GL is declined for whatever reasons, any further treatment is on your own. In this case you may escalate this issue to the Bureau as stated in your third page of the policy if you want to dispute on the claim.

The Dr need to request for a GL, otherwise if you were to seek treatment before getting the GL, it is still a grey area whether the case is cover able.

This is why agent's always advice client to go to panel hospitals (to avoid the pay and claim process) as some illness are not cover able after checking the Exclusion. It's better to get the GL to know for sure that the case is cover able.