I am writing this as a follow-up to your recent survey on insurance approvals for patients undergoing treatment, which was both timely and necessary.
While that article primarily focused on the interference of insurance companies in clinical decision-making, I believe a number of other significant issues have not been addressed.
As a neurosurgeon who has been involved in private practice for over 20 years. I have faced repeated challenges in obtaining approvals for my patients, and not just for the reasons commonly cited.
The unique thing about neurosurgical pathologies is that they are hidden. They lie beneath the skull or spine.
Patients do not know that anything is wrong until something catastrophic happens — compression of vital neural structures, blockage of cerebrospinal fluid leading to hydrocephalus, or a sudden haemorrhage.
These conditions cannot be diagnosed by palpation or auscultation. They require CT scans or an MRI scan.
Some of these conditions are labelled as “congenital” or “developmental” simply because the cells involved originated abnormally during foetal formation.
By true pathological definition, yes, they are congenital. But they remain silent at birth and only manifest decades later often after the patient has long purchased an insurance policy.
Examples include craniopharyngiomas, chordomas, Rathke’s cleft cysts, colloid cysts of the third ventricle, epidermoid cysts and the list goes on. These patients are asymptomatic for 30 to 60 years — until these extremely slow-growing lesions finally cause trouble.
Similarly, patients may develop hydrocephalus due to obstruction or absorption failure. They may compensate for years, until they suddenly deteriorate overnight.
Tethered cord syndrome is another example, the spinal cord fails to ascend before birth. The patient appears normal. Only years later, as growth continues do they develop walking difficulties or urinary problems. There may be minimum external signs. Even doctors may miss it.
The most dangerous, however, is an arteriovenous malformation (AVM). Present since birth — yes. But clinically silent for decades, until it explodes like a time bomb.
And yet in almost all such cases, insurance claims are denied, because a basic pathology report reads “congenital”. Patients are abandoned at the very moment they need help the most, especially in AVM ruptures.
No insurer asked them to undergo a brain scan before selling them a policy. Only smiling faces in brochures, promising instant approval with a swipe of a card or even cardless.
I have repeatedly been asked to justify and re-justify these cases. Do insurance companies not have their own specialists? I fear radiology reports these days, because the mere mention of the word “cyst” or “hydrocephalus” almost guarantees a denial, followed by endless appeals.
I once had a patient with a cystic pituitary tumour. The word “cyst” appeared and the claim was immediately rejected. The patient and family decided to proceed as a pay-and-claim case. Not every family can afford major brain surgery upfront.
Until recently, pituitary adenomas treated endoscopically through the nose were not covered but if we drilled the skull the old-fashioned way, it was covered.
As though a craniotomy from the top of the head is somehow more valid than one from the base of the skull which provides far superior outcomes. I wrote to Bank Negara explaining this absurdity.
The patient eventually got their claim — and to this day, five years on, the patient’s wife brings me cakes. But again the word “cyst” almost always triggers suspicion.
Last Saturday, I was told that a patient needing a biopsy of a deep-seated tumour cannot be admitted the day before if surgery is on a Monday. The patient can only be admitted at 12:01am on Monday — before an 8.00 a.m. surgery — so that the insurer avoids paying for a Sunday admission.
Who will bear the responsibility if something is missed in the rushed hours before brain surgery? Does a few hundred ringgit trump patient’s psychological and physiological well-being before major surgery?
Patients undergoing major surgery may require most recent blood results and repeat clinical examinations as their situation may have changed. In a government hospital, these patients would have required admission a day or more prior to surgery for final assessments.
Insurance companies must be transparent when policies are sold. It may be buried in fine print that “congenital conditions are not covered” but does anyone explain what that actually means?
Does anyone clarify that many life-threatening neurological conditions only manifest decades later? No. And when a guarantee letter is denied, it feels predatory. There is no other word for it.
And this is only neurosurgery. I am certain my colleagues in other specialties face equally ridiculous denials, especially whenever the word “congenital” appears.
Postoperative MRI surveillance every four, six, or 12 months is standard, evidence-based care. Yet unless you have a platinum-tier policy, it is not covered. MRI is expensive globally and unlike other specialties, we cannot “look inside”.
Some insurance agents even advise patients to get their doctor to “admit for MRI” just to force coverage, but the insurance company will then question us and still reject the claim, are these agents not told what they are advising their patients is not acceptable.
If insurance companies do not wish to cover congenital or long-term neurosurgical follow-ups, then declare it boldly, in all four major Malaysian languages, on the policy front page like a cigarette pack warning. No more proposal brochures with smiling people in an hospital environment, as hiding behind fine print is unethical.
This is not a tirade, it is an urgent call for accountability. These systemic problems have persisted for years. And nothing has changed.
Dr Vicknes Waran is a consultant neurosurgeon.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.