KUALA LUMPUR, March 16 — Prudential Assurance Malaysia Berhad (PAMB) paid out more than RM1 million in claims within one policy year to a policyholder undergoing breast cancer treatment in 2025.

The insurance company said the female policyholder of senior age required multiple surgeries, prolonged stay in an intensive care unit (ICU), and advanced cancer therapies and highly specialised cancer drugs. 

“This reflects the significant advances in oncology today and the increasing complexity of care. It also aligns with Malaysia’s continued progress in expanding access to advanced medical capabilities, where specialised cancer treatments are increasingly available to support complex care needs,” PAMB chief health officer Manisha Keyal told CodeBlue in an email interview.

“In moments like these, insurance plays an important role in supporting customers during such difficult periods. This case also highlights the foresight the policyholder demonstrated in planning ahead for her future, ensuring the necessary financial protection was in place when it mattered most, and allowing care decisions to be guided by medical need rather than financial concerns.”

In reference to the RM1.04 million breast cancer case, Manisha stressed that all claims are assessed and paid strictly in accordance with the benefits, limits, and conditions provided under the policy contract. 

PAMB explained that higher annual limits for health insurance are designed to ensure policyholders have sufficient financial protection against increasingly high medical costs, particularly for serious illnesses requiring prolonged or complex treatment.

“In 2013, plans with annual limits of RM50,000 or RM100,000 were common, but such limits would no longer adequately support health care needs today, particularly when considering post-hospitalisation care and the possibility of multiple admissions within a year,” Manisha said.

“Insurance is about covering for what’s unprecedented.”

PAMB stressed the importance of maintaining adequate protection, saying health care needs were “often unpredictable”, as it shared a customer story about a policyholder who was diagnosed with hemangioma shortly after his father stopped paying for the family’s policies due to tight finances.

CodeBlue had asked PAMB if annual limits of RM1 million and above were merely a “marketing tactic” to get new customers, and that claim payouts and premium rates are actually based on the claims experience, not the policy limit.

“Premiums are determined through actuarial pricing based on factors such as claims experience, medical inflation, health care utilisation patterns, and the policyholder’s age or health status. Annual limits therefore exist to ensure customers have adequate financial protection, rather than serving as a marketing feature,” Manisha replied.

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. 

PAMB’s assertion that an RM100,000 annual limit for medical plans is outdated by more than a decade – based on its own claims experience – 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’s annual limit is RM150,000 for above-60s.

The central bank’s White Paper on the Base MHIT cited 2024 data from the Insurance Services Malaysia on medical claims that showed RM55,225 individual claim payouts in the 99th percentile. 

PAMB, however, declined to share detailed claims statistics in response to CodeBlue’s request for data on its average medical claim payout over the past five years. 

“In 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,” said Manisha.

“Claim 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.”

Medical Claim Payouts Doubled In Two Years

Prudential Assurance Malaysia Berhad’s (PAMB) office in Kuala Lumpur. Photo by PAMB.

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. 

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.

Based on PAMB’s claims experience, Manisha attributed rising medical costs in Malaysia to higher health care utilisation and increasing treatment complexity.

“These 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.”

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.

“These 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.”

Medical Claim Approval Rates Exceed 90% Industry Average

PAMB said its medical claim approval rates exceeded the 90 per cent average in Malaysia’s insurance and takaful industry, describing it as the sector’s commitment to paying “legitimate” claims.

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’s coverage terms.

“Clinical decisions remain the responsibility of the treating doctor,” said Manisha.

“In 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.

“At 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.”

In CodeBlue’s October 2025 survey 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. 

“Where 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,” said Manisha.

Transparency In Selling Medical Insurance

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.

All newly appointed Prudential agents are required to complete mandatory training and pass an assessment before they are authorised to sell insurance products.

“This training includes identifying potential anti-selection risks, understanding customers’ protection and financial needs, and ensuring that customers disclose all medical conditions that are material and relevant during the application process,” said Manisha, in response to a question about the communication of policy exclusions and pre-existing conditions at the point of sale.

“Agents 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.

“In 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.

“These measures are part of Prudential’s ongoing efforts to ensure transparency and responsible sales practices, while helping customers better understand their coverage and obligations when purchasing an insurance policy.”

Manisha did not say if health screenings were mandatory to buy medical insurance from PAMB, aside from voluntary disclosures. 

In CodeBlue’s survey, many specialist doctors complained that coverage was often denied or GLs were revoked on the basis of “pre-existing conditions”, especially diabetes, even though these newly detected chronic conditions were unrelated to the admission diagnosis. 

According to the National Health and Morbidity Survey (NHMS) 2023, about 3.6 million adults (15.6 per cent) have diabetes, but two in five are unaware of their diabetic status.

Range Of Medical Protection Solutions Offered

PAMB declined to answer questions about the Base MHIT, such as whether Prudential would cover pre-existing conditions if it decided to offer the government-designed product.

Health Minister Dzulkefly Ahmad announced last month that the Base MHIT would cover pre-existing conditions, without disclosing further details.

“As the Base MHIT framework is still under internal review, we are not in a position to comment on specific product features or coverage considerations at this stage,” Manisha told CodeBlue.

When asked if Prudential currently had medical products of better value than the Base MHIT, like similarly priced plans but with higher annual limits than RM100,000, PAMB was diplomatic in its response.

“As part of the broader health care ecosystem, we continue to engage with policymakers and industry stakeholders as discussions on the Base MHIT framework progress,” said Manisha.

“While doing so, we currently offer a range of medical protection solutions designed to address the evolving needs of customers across different life stages and health care needs while supporting efforts to improve access to sustainable health care protection for Malaysians.

“As the Base MHIT framework is still being reviewed internally, we are not in a position to comment on how it may compare with existing products at this time.”