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Medical Claims


What is a Medical Claim? 

A claim towards incurred medical expenses due to illnesses / diseases / accidental / injuries /disabilities of the Insured Person who is covered under our medical insurance policy.


Who can make a Medical Claim? 

Only valid for medical insurance policyholders.

How To Make A Claim?

For Admissions

  • Call the 24-Hour AmGeneral Call Centre for the location of the nearest AmGeneral Panel Hospitals. Remember this number: 03-22632355
  • Present your Medical Card at the Admissions Counter.
  • If the policy is in force and the condition is covered, a Guaranteed Letter will be sent. If not, a Letter of Decline will be issued.
  • If successful, you may be required to pay a deposit, based on hospital requirements, before admission.
  • For discharge processing, the Panel Hospital will prepare the Discharge Documentation to be processed by AmGeneral Medical Insurance Department. A Payment Advice will be produced.
  • You will be discharged upon settling incidentals or non-covered expenses.


For Reimbursement Claims

  • If you choose to be admitted to a non-AmGeneral Panel Hospital under Reimbursement Claims Procedures, you will need to send us a written notification within 30 days of admission.
  • Complete Claims Documentation must be submitted within 30 days from the discharge date, consisting of:
  • Other Relevant Claims Documents
  • Completed Physician’s Medical Report
  • Complete Claim Form
  • Original Itemized Bills & Receipts
  • For covered conditions, an offer letter and claims payment will be sent. Sometimes, a discharge voucher will be issued first on the amount payable without claims payment, if deemed necessary. AmGeneral will only proceed to issue claims payment upon receipt of the signed discharge voucher.

What Are The Supporting Documents?

  1. Original Medical Report / Discharge Summary ( to be completed and signed by Doctor / Physician / Specialist / Surgeon)
  2. Original Completed Claim Form (to be completed and signed by Policyholder and claimant)
  3. Original itemized breakdown medical bill/tax invoice
  4. Original official receipt
  5. Copy of Identity Card
  6. Copy of Referral Letter to hospital (if any)
  7. Police report (if Motor Vehicle Accident involved)
  8. Driver’s Driving License (if Motor Vehicle Accident involved)
  9. Copy of examination reports such as imaging and pathology reports (if any)

General FAQ

1. Will I be covered if I travel overseas for vacation or on business trip?

Yes, provided you: -

  • Are away from Malaysia for not more than ninety (90) consecutive days
  • Needs to be confined to a hospital outside Malaysia as a consequence of a Medical Emergency. Overseas treatment of a disease, sickness, or injury which is non-emergency or non-critical where treatment can reasonably be postponed until return to Malaysia are excluded.
  • Needs to receive an emergency accidental out-patient treatment within 24 hours of the accident

Coverage is in the form of reimbursement basis upon submission of complete claim documents to us.


2. Is there a limit to the number of claim I can make during the 12 months cover?

No, as long as the claim is still within the Overall Annual Limit. 


3. What is “Waiting Period”?

“Waiting Period” means any claim falls within the 30 days from the effective date of the policy will not be covered unless it is due to an accident. However, this waiting period is not applicable to renewal policy and take-over policy.


4. What is Pre-Existing Illness exclusion? Can it be waived?

Pre-Existing Illness exclusion shall means exclusion of disabilities that Insured has reasonable knowledge of. The condition is one for which:

a)   The Insured had received or is receiving treatment

b)   Medical advice, diagnosis, care or treatment has been recommended

c)   Clear and distinct symptoms are or were evident

d)   Its existence would have been apparent to a reasonable person in the circumstances.

This exclusion generally will not be waived.  


5. What is “Specified Illness”?

“Specified Illness” shall mean the following disabilities and its related complications, occurring within the first 120 days of Insurance of the Insured Person:

a)         Hypertension, diabetes mellitus and cardiovascular disease

b)         All tumours, cancers, cysts, nodules, polyps, stones of the urinary system and biliary system

c)         All ear, nose (including sinuses) and throat conditions

d)         Hernias, haemorrhoids, fistulae, hydrocele, varicocele

e)         Endometriosis including disease of the reproduction system

f)          Vertebro-spinal disorders (including disc) and knee conditions.


6. Would I be able to request a guarantee letter if I forgot to bring or have lost my medical card?

Yes. You can call our 24 hours medical hotline at 03-22632355 for further assistance. We will verify your insured status and proceed to administer your admission accordingly. 


7. What should I do if I have a pre-arranged hospital admission or day surgery?

If your doctor has confirmed that a hospitalization or day surgery is required during your outpatient visit, please inform the hospital admission staff to arrange accordingly. The hospital will request guarantee letter from us. This will eliminate the waiting time for guarantee letter issuance on the actual admission day.


8. If a guarantee letter has been issued, does that mean that all hospitalization expenses are paid?

The guarantee letter will cover the Insured medical expenses up to his or her eligible limits according to the policy terms and conditions. The Insured may be required to pay the excess charges that are not covered under the policy benefits such as telephone charges, extra meals, purchase of aid equipment, etc. Certain hospital might collect a minimal deposit at the time of admission to cover for these non-payable items. Any excess of this deposit after deducting the non-payable expenses will be refunded during discharge.


9. What is “Reasonable And Customary Charges”?

The reasonable and customary charges shall mean charges for medical care which is medically necessary shall be considered reasonable and customary to the extent that it does not exceed the general level of charges being made by others of similar standing in the locality where the charge is incurred, when furnishing like or comparable treatment, services or supplies to individual of the same sex and of comparable age for a similar sickness, disease or injury and  in accordance with accepted medical standards and practice could not have been omitted without adversely affecting the Insured Person’s medical condition.

The 13th Schedule Fee is adopted as the Customary and Reasonable Charges.


10. What is “Medically Necessary”?

A “Medically Necessary” shall mean a medical service, which is:

a)   Consistent with the diagnosis and customary medical treatment for a covered disability,

b)   In accordance with standards of good medical practice, consistent with current standard of professional medical care, and of proven medical benefits,

c)   Not for the convenience of the Insured or the Physician, and unable to be reasonably rendered out of hospital,

d)   Not of an experimental, investigational or research nature, preventive or screening nature,

e)   And for which the charges are fair and reasonable and customary for the disability.


11. What is the minimum period of confinement?

Twelve (12) consecutive hours. However, no minimum period of hospital confinement is required if such confinement is in connection with a surgical operation or accidental emergency treatment.


12. What is the 20% Up-Graded Room and Board Co-Payment?

The 20% Co-Payment will apply to other eligible benefits if the Insured Person is hospitalized at a published Room and Board rate which is higher than his eligible benefit subject to a maximum limit of RM3,000 per Disability for plans with Overall Annual Limit not exceeding RM100,000 or subject to a maximum limit of RM5,000 per Disability for plans with Overall Annual Limit exceeding RM100,000.


13. Under what circumstances that a guarantee letter is not approved and I would have to settle my own bill? Can I submit a claim after that?

The following could be the reasons: -

a)   Policy lapsed/terminated

b)   The condition diagnosed falls within exclusions under the policy terms and conditions such as pre-existing illness, specified illness, waiting period etc.

c)   The hospital that you were admitted is not under our panel list

d)   Hospital admission is primarily for investigations not leading to any treatment required.

e)   The treatment done can be on an out-patient basis only

f)   It is for outpatient, pre-hospitalization or post-hospitalization treatment

g)   Hospitalization outside of Malaysia

You may settle the bill first and file for reimbursement consideration, subject to your policy’s terms and conditions.  


14. A final guarantee letter was issued to the panel hospital for my admission. How can I find out what are the non-payable charges of my hospitalization bill?

You may request a copy of Payment Advice from hospital personnel, which indicates the breakdown for non-insured items and the fees. 


15. Can I claim my medical expenses if they have been fully reimbursed by my employer or another insurance policy?

If your medical expenses have been fully reimbursed by a third party, you will not receive further reimbursement from the policy. However, you are still entitled to daily hospital cash allowance if you are hospitalized due to a covered medical condition in a Malaysian fully government hospital.