Insurance

MediAsas Claims: Steps, Common Rejection Reasons and Prevention

MediAsas claims work through either cashless admission via a Guarantee Letter at panel hospitals or manual reimbursement elsewhere. Knowing whether you hold a MediAsas Teras or Fleksi plan determines your exact deductible and co-payment at discharge. Preparing your documents and verifying coverage beforehand helps you avoid preventable claim rejections.

Author Bowtie Team

Date 2026-11-11

Updated on 2026-11-13

Why Understanding the MediAsas Claims Process Matters

Understanding the MediAsas claims workflow before a medical emergency occurs protects you from unexpected out-of-pocket bills and administrative delays at the hospital counter. Introduced under Bank Negara Malaysia’s (BNM) RESET healthcare reform strategy alongside the Ministry of Health (MOH) and Ministry of Finance (MOF), MediAsas is a standardised, standalone medical insurance and takaful plan. While its features are uniform across participating insurers and takaful operators (ITOs), how your hospital bill is settled depends heavily on where you seek treatment and how well you follow pre-authorisation steps.

When you need hospitalisation or day surgery, your claim follows one of two main pathways:

Direct Billing (Cashless Facility): Available when you are admitted to a Preferred In-Network Provider. Your insurer or takaful operator issues a Guarantee Letter (GL) and settles the eligible portion of your hospital bill directly with the medical centre.
Reimbursement (Pay and Claim): Required when you visit an out-of-network hospital, if a Guarantee Letter is not issued, or when you claim for eligible pre- and post-hospitalisation outpatient visits. Under this route, you pay the medical provider upfront and submit your itemised bills and medical reports to your operator for reimbursement.

Knowing how to navigate both routes ensures you do not accidentally trigger higher cost-sharing charges during a stressful health event.

Step 1: Locating the Right Facility on the MediAsas Panel Hospitals List

Checking the MediAsas panel hospitals list—officially termed Preferred In-Network Providers—is the essential first step before scheduling any non-emergency medical treatment. Under the MediAsas framework, Preferred In-Network Providers are private hospitals enlisted by ProtectHealth Corporation Sdn. Bhd. (ProtectHealth) or an authorised government entity that meet strict clinical quality and cost-efficiency standards. Choosing a hospital on this list directly reduces your out-of-pocket expenses and unlocks direct billing facilities.

Before heading to a medical centre, keep the following points in mind regarding the network list:

How to Verify Your Hospital: Because the network list is updated periodically to reflect new hospital partnerships and service standards, you should verify whether your preferred facility is on the mediasas panel hospitals list via your participating insurer or takaful operator’s mobile app, online portal, or customer service hotline prior to admission.
Access to Cashless Admission: Staying in-network gives you access to Guarantee Letter facilities, sparing you from having to pay tens of thousands of ringgit upfront upon admission.
Greater Billing Certainty via DRG: MediAsas integrates a phased shift towards Diagnosis-Related Group (DRG) payment models at network hospitals. Instead of unpredictable fee-for-service itemised charges, treatment costs are anchored to transparent, pre-negotiated cost bands based on your diagnosis and condition severity.
Lower Cost-Sharing Rates: If you visit an out-of-network private hospital for non-emergency care, you will lose cashless privileges and face higher cost-sharing—specifically an extra 20% co-payment under MediAsas Teras or a higher RM15,000 annual deductible under MediAsas Fleksi.
Room and Board Rules: MediAsas covers shared rooms (two-bedded or four-bedded, depending on availability) with no daily monetary cap, up to 150 days per disability. If a shared room is unavailable at a panel hospital during admission, the hospital provides a free upgrade to a private room. However, at an out-of-network hospital, reimbursement is strictly capped at the equivalent shared room rate, and you must pay any excess room charges yourself.

Step 2: Securing MediAsas Cashless Hospital Admission via Guarantee Letters

Securing a mediasas cashless hospital admission requires obtaining a Guarantee Letter (GL) through a pre-authorisation process at a Preferred In-Network Provider. A Guarantee Letter is a formal undertaking from your insurer or takaful operator to the panel hospital confirming that your planned treatment is eligible under your policy or certificate, allowing the hospital to bill the operator directly for covered charges.

To ensure a smooth admission and discharge experience at a panel hospital, follow these chronological steps:

Confirm Coverage Before Admission: For planned procedures or day surgeries, speak with your attending doctor and contact your insurer or takaful operator beforehand to confirm that your medical condition and proposed treatment are covered under your MediAsas policy.
Register at the Hospital Admission Counter: Present your National Registration Identity Card (NRIC) alongside your physical or digital MediAsas medical card at the panel hospital’s admission desk.
Submit the Pre-Authorisation Request: Your attending doctor will complete the medical section of the pre-authorisation form detailing your diagnosis, symptom onset date, and treatment plan, which the hospital then submits to your operator.
Await the Initial Guarantee Letter: Once the operator verifies that your condition is medically necessary and falls outside waiting periods or exclusions, an Initial GL is issued to the hospital. Note that hospitals may still request a small refundable administrative deposit to cover personal items or your applicable deductible.
Undergo Treatment and Await the Final GL: When your doctor clears you for discharge, the hospital compiles your final bill and sends it to your operator. Once the Final GL is approved, review the bill carefully, settle your deductible or non-covered personal items at the cashier, and head home.

Step 3: Discharge and Out-of-Pocket Costs (MediAsas Co-Payment and Deductible Explained Plainly)

Even when your cashless admission is approved via a Guarantee Letter, you will still need to pay your portion of the mediasas co payment and deductible before being discharged. In plain English, ”cashless admission” means your insurer pays its covered share directly to the hospital so you do not have to pay the entire hospital bill upfront. However, because MediAsas is designed to keep monthly premiums affordable and curb unnecessary hospital utilisation, every policyholder shares a predetermined portion of the treatment cost.

To understand what you will pay at the discharge counter, it helps to distinguish between two key terms:

Deductible: The fixed upfront ringgit amount you must pay out of your own pocket before your MediAsas plan starts paying for the rest of the eligible bill.
Co-Payment (Co-Insurance / Co-Takaful): The percentage of the remaining eligible hospital bill that you must share after the deductible has been deducted.

Your exact out-of-pocket amount upon discharge depends on whether you are enrolled in MediAsas Teras (the standard plan) or MediAsas Fleksi (the higher-deductible plan with a higher annual limit), as well as whether you visited a panel or non-panel hospital:

MediAsas Teras Cost-Sharing (Per Disability):
- Overall Annual Limit: RM100,000 for ages 0 to 59 (age last birthday), increasing to RM150,000 for ages 60 and above.
- At Panel Hospitals (Preferred In-Network): You only pay a fixed deductible of RM500 per disability if you are aged 0 to 59, or RM1,000 per disability if you are aged 60 and above. No percentage co-payment applies in-network. (A ”per disability” deductible covers all admissions arising from the same medical cause and its complications, unless you fully recover and remain treatment-free for at least 90 consecutive days).
- At Non-Panel Hospitals (Out-of-Network): On top of the RM500 or RM1,000 deductible, you must also pay a 20% co-payment (co-insurance or co-takaful) on the remaining eligible bill, capped at RM3,000 per disability.
MediAsas Fleksi Cost-Sharing (Per Annum):
- Overall Annual Limit: RM300,000 across all eligible age groups.
- At Panel Hospitals (Preferred In-Network): You bear an annual deductible of RM10,000 per policy year. Once your cumulative eligible medical bills cross RM10,000 within that year, the plan covers the remaining eligible costs up to RM300,000 with 0% co-payment.
- At Non-Panel Hospitals (Out-of-Network): Your annual deductible increases to RM15,000 per policy year, with no additional percentage co-payment. (This plan is often paired with existing employer medical benefits to cover catastrophic bills).
Situations Where Cost-Sharing is Waived (MediAsas Teras Only):
- Under MediAsas Teras, both the deductible and the 20% co-payment are completely waived (meaning RM0 cost-sharing on eligible items) in three specific scenarios: (1) Emergency treatments, (2) Outpatient cancer treatments, and (3) Admissions to Malaysian Government Healthcare Facilities.
- Note that this cost-sharing waiver does not apply to MediAsas Fleksi, where the RM10,000 or RM15,000 annual deductible remains applicable across all claims.

Step 4: The Reimbursement Route — How to Claim MediAsas for Non-Panel or Post-Hospitalization Bills

Knowing how to claim mediasas manually via the ”Pay and Claim” reimbursement method is essential whenever you seek treatment outside the panel network or pay upfront for outpatient care. While inpatient admissions at Preferred In-Network Providers are typically settled via a Guarantee Letter, you will need to pay first and file a reimbursement claim if you are admitted to an Out-of-Network Provider, if a pre-authorisation GL could not be issued in time, or when you claim for eligible outpatient expenses.

Under MediAsas, eligible bills that frequently require manual reimbursement include Pre-Hospitalisation Treatment (consultations, diagnostic tests, and medications incurred within 30 days prior to your hospital admission), Post-Hospitalisation Treatment (follow-up care and medications within 90 days after discharge), and Outpatient Illness Treatment at hospital outpatient departments (up to RM3,000 per year for specific conditions: Dengue Fever, Bronchitis, Influenza A & B, and Pneumonia/Bronchopneumonia).

To file a successful reimbursement claim without delays, follow these steps:

Settle the Bill Upfront: Pay the hospital or specialist clinic directly at the end of your visit or upon discharge.
Collect All Mandatory Original Documents Before Leaving: Never leave the hospital billing counter without a complete document pack. Ensure you request:
- Original Official Receipts: Proof of payment showing the exact amount settled.
- Fully Itemised Billing Statements: A line-by-line breakdown of every medication, consultation fee, room charge, and medical supply (summary credit card slips are not accepted).
- Attending Physician’s Medical Report / Claim Form: Completed and signed by your treating doctor, stating the exact diagnosis, date symptoms first appeared, and treatment details.
- Diagnostic and Laboratory Results: Copies of blood test reports, X-rays, MRI/CT scan findings, or histopathological reports related to the admission.
- Discharge Summary: Provided by the hospital upon inpatient discharge.
Submit Your Claim Within the Stipulated Timeframe: Log in to your participating insurer or takaful operator’s digital claims portal (or submit through your servicing agent) as soon as possible after discharge—typically within 30 days of treatment—uploading clear scans of all documents while keeping the physical originals safe in case the operator requests them.
Track Adjudication and Receive Your Payout: If any supporting details are missing, your operator will notify you to provide the required documents. Once approved, the operator will deduct any applicable deductible, out-of-network 20% co-payment, or excess room upgrade charges, and credit the net reimbursement directly into your registered bank account via electronic funds transfer.

Troubleshooting: Common MediAsas Claim Rejection Reasons and How to Prevent Them

Even with a standardised national scheme, policyholders sometimes face unexpected hurdles during claims assessment. Being aware of common mediasas claim rejection reasons—such as undisclosed medical history, claiming during the waiting period, or seeking non-covered procedures—can save you from significant financial shock. Importantly, BNM guidelines stipulate that making legitimate claims under MediAsas will not cause your individual renewal premiums to be penalised, as pricing adjustments are strictly portfolio-wide.

However, insurers and takaful operators will reject or contest claims that breach policy terms. A crucial consumer protection rule under MediAsas is the 7-year moratorium period (often called the ”no look-back” clause): once your policy has been continuously in force for seven years from the Risk Commencement Date, your operator cannot contest a claim on the grounds of innocent non-disclosure or misrepresentation—unless there was fraudulent, deliberate, or reckless omission, or the claim involves a Pre-Defined Medical Condition that existed before or within 30 days of your policy start date.

Common Claim Rejection or Delay Reason	Why It Happens Under MediAsas Rules	Actionable Prevention Steps for Policyholders
Claiming Within the Waiting Period	Any medical condition arising within the first 30 days of the Risk Commencement Date (or reinstatement) is excluded, except for accidental injuries. Additionally, a 120-day waiting period applies to treatments or surgeries for Specified Illnesses (such as hypertension, diabetes, cardiovascular disease, tumours, cysts, or gallstones).	Check your policy start date before scheduling elective procedures. Never allow your policy to lapse, as reinstating a lapsed medical card restarts the 30-day and 120-day waiting periods from scratch.
Non-Disclosure of Pre-Existing Conditions	MediAsas is a fully underwritten plan. While some applicants with stable pre-existing conditions (such as early-stage cancer in remission) may be accepted with specific condition exclusions, omitting medical history during application allows the operator to deny claims for deliberate or reckless non-disclosure.	Declare your full medical history—including past diagnoses, ongoing medications, and doctors’ advice—honestly in the health questionnaire at enrolment. Honest declaration ensures your policy remains valid and protects you under the 7-year moratorium.
Falling Under Standard Policy Exclusions	MediAsas enforces standard exclusions across all operators. These include congenital or hereditary conditions, routine screening or preventive check-ups not medically necessary for hospitalisation, weight management treatments, cosmetic procedures, communicable diseases legally requiring isolation/quarantine, and all medical treatments outside Malaysia.	Review your Product Disclosure Sheet and exclusion list before admission. Ensure any inpatient admission is certified by your doctor as ”Medically Necessary” for treating a specific disability, not just for routine diagnostic investigation.
Unverified Non-Emergency Admissions or Switching Hospitals	Proceeding with non-emergency treatment without confirming coverage, or switching hospitals/doctors midway through ongoing treatment without prior insurer approval, can invalidate your Guarantee Letter or trigger a review of your co-payment waiver.	Always obtain pre-authorisation at a Preferred In-Network Provider before admission. Avoid changing hospitals during an active admission unless medically necessary and pre-approved by your operator.
Incomplete or Summary Billing Documents	Submitting a ”Pay and Claim” request with only a lump-sum receipt or missing the attending doctor’s medical report prevents the operator from verifying that charges fall within covered benefit limits.	Always request a fully itemised hospital bill, official payment receipts, diagnostic reports, and a signed physician’s statement before leaving the medical facility.

If you believe your MediAsas claim was unfairly rejected or your payout was miscalculated, you have the right to submit a formal appeal with supporting medical evidence to your insurer or takaful operator. If the dispute remains unresolved after the operator’s internal review, you can escalate the case to the Financial Markets Ombudsman Service (FMOS) or Bank Negara Malaysia’s BNMLINK for independent mediation.

Disclaimer

The information provided in this article is for educational purposes only and does not constitute financial, insurance, or medical advice. MediAsas information reflects pilot terms and guidelines that may be subject to change by the relevant authorities. Please refer to the official policy documents for exact coverage details.

Frequently Asked Questions

Can I get cashless admission at any private hospital in Malaysia with MediAsas?

No. Cashless hospital admission via a Guarantee Letter (GL) is only available at Preferred In-Network Providers (panel hospitals) enlisted under the MediAsas network. If you seek treatment at an out-of-network private hospital, you must pay the medical expenses upfront and submit a manual reimbursement claim (”Pay and Claim”) afterward, which will also be subject to higher out-of-network cost-sharing.

Do I still need to pay anything at discharge if my MediAsas cashless admission is approved?

Yes. While an approved Guarantee Letter means your insurer or takaful operator pays its covered portion directly to the panel hospital, you must still settle your applicable deductible before discharge—such as RM500 per disability (for ages 59 and below) or RM1,000 (for ages 60 and above) under MediAsas Teras, or RM10,000 per annum under MediAsas Fleksi. You are also responsible for any non-covered personal items or voluntary room upgrades.

Are there situations where the MediAsas deductible and co-payment are waived?

Yes, but only if you hold the MediAsas Teras plan. Under MediAsas Teras, both the deductible and the 20% out-of-network co-payment are completely waived for: (1) emergency treatments, (2) outpatient cancer treatments, and (3) treatments sought at Malaysian Government Healthcare Facilities. This cost-sharing waiver does not apply to the MediAsas Fleksi plan.

Can I submit a MediAsas claim for emergency medical treatment received overseas?

No. All benefits and coverage under MediAsas apply strictly to eligible medical treatments received within Malaysia. Any medical bills incurred outside Malaysia—even for emergencies—are excluded and cannot be claimed under MediAsas.

Will making a MediAsas claim cause my personal monthly premium to increase at renewal?

No. Under Bank Negara Malaysia’s MediAsas guidelines, insurers and takaful operators do not penalise or adjust an individual’s renewal premiums or contributions based on personal claims history. Any future pricing adjustments are determined strictly by the overall performance and sustainability of the collective MediAsas portfolio.

Sources

Author

Bowtie Team

Bowtie Life Insurance Company Limited was founded in 2018, as the first authorised virtual insurance company in Hong Kong. Within only 2 years, Bowtie has been providing a wide range of medical coverage to the Hong Kong public. We would like to continue sharing insurance and medical knowledge with people worldwide with our professional expertise and passions.

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