CodeBlue had asked PAMB if annual limits of RM1 million and above were merely a \u201cmarketing tactic\u201d to get new customers, and that claim payouts and premium rates are actually based on the claims experience, not the policy limit.<\/p>\n
\u201cPremiums are determined through actuarial pricing based on factors such as claims experience, medical inflation, health care utilisation patterns, and the policyholder\u2019s age or health status. Annual limits therefore exist to ensure customers have adequate financial protection, rather than serving as a marketing feature,\u201d Manisha replied.<\/p>\n
Aside from its breast cancer case last year with RM1.04 million payouts, PAMB said the highest individual medical claim in 2024 reached RM732,000.\u00a0<\/p>\n
PAMB\u2019s assertion that an RM100,000 annual limit for medical plans is outdated by more than a decade \u2013 based on its own claims experience \u2013 comes after Bank Negara Malaysia (BNM) contended that the RM100,000 annual limit for its proposed base medical and health insurance\/takaful (MHIT) product for under-60s could cover 99 per cent of treatment episodes across a range of common medical conditions, including the possibility of multiple admissions. The Base MHIT\u2019s annual limit is RM150,000 for above-60s.<\/p>\n
The central bank\u2019s White Paper on the Base MHIT<\/a> cited 2024 data from the Insurance Services Malaysia on medical claims that showed RM55,225 individual claim payouts in the 99th percentile.\u00a0<\/p>\n PAMB, however, declined to share detailed claims statistics in response to CodeBlue\u2019s request for data on its average medical claim payout over the past five years.\u00a0<\/p>\n \u201cIn 2022, Prudential paid more than RM1 billion in claims, with this amount doubling to more than RM2 billion in 2024. This utilisation trend is expected to continue over the medium term,\u201d said Manisha.<\/p>\n \u201cClaim sizes vary depending on the complexity of the medical condition and treatment required. While many claims relate to routine treatments or shorter hospital stays, more complex conditions such as cancer treatment, major surgery, or prolonged hospitalisation can result in significantly higher payouts.\u201d<\/p>\n Medical Claim Payouts Doubled In Two Years<\/strong><\/p>\n PAMB data shows that policyholders aged 60 and above recorded the highest medical claim payouts, while 52 per cent of medical claims were made by female policyholders.\u00a0<\/p>\n Among the most common medical conditions claimed from Prudential in 2024 were heart disease, breast cancer, cataract, pneumonia, and gastritis, with payouts ranging from RM64 million to RM120 million.<\/p>\n Based on PAMB\u2019s claims experience, Manisha attributed rising medical costs in Malaysia to higher health care utilisation and increasing treatment complexity.<\/p>\n \u201cThese trends are consistent with broader observations across the health care ecosystem, including increasing longevity, the growing prevalence of non-communicable diseases (NCDs) such as heart disease, cancer and diabetes, lifestyle-related health risks, and continued advances in medical technology and treatment capabilities.\u201d<\/p>\n PAMB further observed increasing hospital utilisation through higher admission volumes and claims, citing the 100 per cent increase in its medical claim payouts within two years from RM1 billion in 2022 to RM2 billion in 2024.<\/p>\n \u201cThese trends mirror broader national discussions on health care financing sustainability, and Prudential continues to work with health care providers, policymakers and industry stakeholders to support efforts aimed at ensuring Malaysians have access to quality care while maintaining a sustainable health care system.\u201d<\/p>\n Medical Claim Approval Rates Exceed 90% Industry Average<\/strong><\/p>\n PAMB said its medical claim approval rates exceeded the 90 per cent average in Malaysia\u2019s insurance and takaful industry, describing it as the sector\u2019s commitment to paying \u201clegitimate\u201d claims.<\/p>\n In response to a question about the conditions of guarantee letter (GL) withdrawals, PAMB said GLs are issued based on clinical information provided by the treating doctor and hospital at the point of admission and are assessed against the policy\u2019s coverage terms.<\/p>\n \u201cClinical decisions remain the responsibility of the treating doctor,\u201d said Manisha.<\/p>\n \u201cIn a small number of cases, a guarantee letter may be revised if new or materially different medical information emerges after admission, such as when a final diagnosis differs from the initial assessment.<\/p>\n \u201cAt Prudential, we work closely with our panel hospitals and doctors through regular engagements and refresher briefings to ensure that sufficient and accurate clinical information is provided during the admission stage.\u201d<\/p>\n In CodeBlue\u2019s October 2025 survey <\/a>among more than 850 specialists in private hospitals on health insurance issues, most respondents complained about denials, delays, or revocation of GLs after admission or treatment.\u00a0<\/p>\n \u201cWhere claims are declined, the reasons typically relate to policy conditions or eligibility requirements, such as treatments not covered under the policy, policies not in force, claims submitted outside the allowable post-hospitalisation period, or other underwriting considerations,\u201d said Manisha.<\/p>\n Transparency In Selling Medical Insurance<\/strong><\/p>\n PAMB said it placed strong emphasis on ensuring that policy terms, including exclusions and pre-existing condition clauses, are clearly communicated to customers during the point-of-sale process so they understand their coverage and obligations when purchasing an insurance policy.<\/p>\n All newly appointed Prudential agents are required to complete mandatory training and pass an assessment before they are authorised to sell insurance products.<\/p>\n \u201cThis training includes identifying potential anti-selection risks, understanding customers\u2019 protection and financial needs, and ensuring that customers disclose all medical conditions that are material and relevant during the application process,\u201d said Manisha, in response to a question about the communication of policy exclusions and pre-existing conditions at the point of sale.<\/p>\n \u201cAgents are also trained to explain policy terms and conditions clearly to customers, including waiting periods, exclusions and other important coverage details, both before and after the policy documents are issued.<\/p>\n \u201cIn addition to training, agents are supported by structured sales tools that include a medical disclosure guide to support clear communication with customers during the application process. Agents are also required to complete a checklist to ensure the relevant options and disclosures are properly captured and to minimise the risk of mis-selling.<\/p>\n \u201cThese measures are part of Prudential\u2019s ongoing efforts to ensure transparency and responsible sales practices, while helping customers better understand their coverage and obligations when purchasing an insurance policy.\u201d<\/p>\n Manisha did not say if health screenings were mandatory to buy medical insurance from PAMB, aside from voluntary disclosures.\u00a0<\/p>\n In CodeBlue\u2019s survey, many specialist doctors complained that coverage was often denied or GLs were revoked on the basis of \u201cpre-existing conditions\u201d, especially diabetes, even though these newly detected chronic conditions were unrelated to the admission diagnosis.\u00a0<\/p>\n![\"\"](\"https:\/\/www.europesays.com\/ie\/wp-content\/uploads\/2026\/03\/Prudential-office.jpg\")
Prudential Assurance Malaysia Berhad\u2019s (PAMB) office in Kuala Lumpur. Photo by PAMB.<\/p>\n