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

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.

Check with the panel hospitals pls

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

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

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.

To know the status the GL is very easy.

Once the hospital has provided the necessary info, you can ask your agent to call the H&S 24 Hours hotline (not the Customer Service No) on this. This service is avaliable 24/7 to agents.

I have confirmed to you that Day Surgery works as stated in my earlier post. A GL request is still required for Day Surgery.

For your information the application for the GL (irrespective of whether it is Day Surgery Benefit or normal admission) is between the Doctor and the H&S claims PIC. Whatever that is written in the application for GL will not be made available to the agent. Therefore I am unable to provide you with the said letter. Sorry.

During the application of the GL, if the case is able to be covered under Day Surgery, but the Doctor had requested that hospital admission is required, the H&S will ask the Dr to justify the reason why the admission is necessary.

If the Doctor is able to justify, then the admission will be granted, otherwise a Day Surgery needs to be performed. If admission it means incurring the Room, food and lodging, in hospital facilities, therefore increase the cost.

After the discharge from the hospital (irrespective of whether it is done via Day Surgery or stayed up to 2 weeks at the hospital) Pre-Hospitalization & Post-Hospitalization when submitting the claim form (see the claim form in my previous post, there is a TICK for Day Surgery Benefit), if the procedure is done as a Day Surgery, the agent will select Day Surgery Claim instead of Hospitalization.

Note:
The procedure for applying for the GL for Day Surgery & Normal Admission is the same. The only difference is that Day Surgery, you get treated and go back on the same day, whereas admission is staying at the hospital for more than 1 day.

The outpatient treatment the customer service has mentioned, it is for admission and claim under the POST hospitalization. She did not mention that PruFlexi Med does not cover Day Surgery?

That is why she advise you to apply for GL and if it is coverable, then the H&S will process the application under normal admission or under Day Surgery.

Please note that the deferment of the Day Surgery does not mean that the claim is rejected. It means they need more time to investigate the case.

In this case if the surgery had been performed (pay and claim) one may submit the claim for consideration. I noted below that you mentioned that the cyst burst before the surgery. See below

Frankly I doubt that investigation by Prudential reveals you had taken several months medical leave. Even if they had call your HR, don't you think that your HR will also ask your permission before releasing such information to someone who 'claims' they are from Prudential?

Even if you take medical leave (not saying that you did), it does NOT necessarily mean it was for the cyst, that means there is no proof that the Cyst was a pre-existing medical condition.

You may call the 24/7 H&S to really understand why it was deferred. They are the ones that handles the admission/claims. PM me if your agent does not have the number. Sorry as I am unable to share this no in open forum, otherwise the H&S will be busy with calls that is supposed to go to our CS.

Do you know that you can still file a claim under the Day Surgery benefit for the wound cleansing normal clinic bill? The thing about Cyst is that even after cleaning the wound, it can reoccur. Therefore multiple visits to the clinic may also be required.

However, since there is no GL issuance (meaning Pru doesn't have any record of the case), the Doctor that treated you needs to fill up the Doctors Statement . See my earlier post for the link.

By submitting the claim, then you know for sure for sure (yes its typed twice!) whether the case is declined or accepted for reimbursement basis.

P/S: I had also just help someone (not my client) to claim for abscess removal at the clinic, which was claim under Day Surgery (though his medical card is like 15 years ago PMM3).

The abscess removal at the clinic costs RM400 but unfortunately the Doctor charge RM60 just to write on that Doctors Statement. The medical report if not claim under GL has to be paid by client. He was only reimbursed RM360

TBH, a lot of things even us agents are unable to get our hands on, including the communication of the GL issuance by the Dr & the insurer.

The part that verify your IC/Policy No is in front. Please also include the recording whereby the CS says that PruFlexi Med is not covered for Day Surgery so that I may feedback to Prudential as it is already mentioned in the policy book that Day Surgery is covered.

The CS had also mentioned to you that you need to be admitted OR claim it as Day Surgery. Either way, the Panel Doctor will need to write in to request for the Guarantee Letter if you do not want to pay and file claim.

Once the Dr had write in with the GL request, if the case can be done as a Day Surgery the H&S will suggest to the Dr to do it under Day Surgery where you get treated and go back the same day, there is no need to be admitted.

The Day Surgery works with PruFlexi Med at the panel hospital or non-panel hospital. The only difference is that if you get the Day Surgery done at a non-panel, you need to pay and claim.

BTW, if a person fainted, definitely an admission is required as Doctors will need to run several test to determine the root cause. You can't expect that to be done as an out-patient.

I have stated a few times on how the PruFlexi Med Day Surgery works at non-panel and panel, please read my post again.

Please just ask "Does Pruflexi Med Cover Day Surgery? Yes or No?". Do not ask any other questions please. Thanks

Yes it does. You may transfer the servicing agent to an active agent

This post has been edited by roystevenung: Apr 7 2019, 05:50 PM

Yes the pre & post is based on reimbursement basis, pay and claim. Do understand that not everything is covered by the insurance, eg, vitamins/supplements/wrist band etc.

Any investigations prior to the surgery must be medically necessary and it is related to the illness/disability.

Otherwise, its on your own cost. Therefore, do confirm with the Dr.

In any case, once the last follow (post hospitalization) is completed (limited to the 90 days after the surgery), submit all the bills/receipts/invoices/reports for claims considerations. Anything that is claimable will be paid, whilst anything that is not claimable will be deducted from the bill.