FAQ  -  Hassle-free Hospital Admission  -  B-HealthNet
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 What are the special features?
How does Hassle-free Hospital Admission work?
Is there any criteria of Pre-Certification?
What if Pre-Certification fails?
Can I cover my child?
Is there a waiting period?
When can the policy be effected?
What is the role of the MCO?
Does take-over condition applies for B-Health Wise/Elite to shift over?
How about Take Over from Other Insurer Health Plan?
For Family Plan how many spouses and children are allowed?
Is RM2,500 the limit for Guarantee Letter for Hospital admission by MCO?
Who is responsible to pay the ineligible expenses upon discharge?
Is there a restriction of panel of hospitals by PMC?
Is Oversea Treatment eligible for Pre-Certification?
Do claimant has to submit claim form when admission is arranged by PMC?
What is not covered?
If the Insured is known to have suffered from existing condition before the effective date of the insurance, is it termed as pre-existing and if so when will such coverage of the condition commence?

  
1 What are the special features?

a) Hassle-free hospital admission
b) Eligible medical expenses payable on "Full reimbursement" up to Overall Annual Limit
c) Annual Outpatient Cancer or Kidney Dialysis Treatment
d) Organ transplant full reimbursement up to Overall Annual Limit
e) Accompanying lodger benefits not confined to being a covered Insured
f) Home Nursing Care Benefit
g) Hospital Income for Accident Confinement                                                             
h) Emergency Medical Assistance
i) Renewable up to 70 years

2 How does Hassle-free Hospital Admission work?
A)  Non-emergency hospital treatment or surgery, Pre-Certification is required by MCO as follows:

1. Contact our appointed Managed Care Organization (MCO), Pantai Medicare (PMC).
2. PMC will need to verify your eligibility and issue you an initial Guaranteed Letter (RM2,500) for your hospital 
    admission.
3. PMC will obtain from you or your attending physician a preliminary diagnosis report and forwarded to  Berjaya
    General Insurance Bhd (BGI).
4. After validation of your preliminary diagnosis to determine that the condition requiring treatment is a covered
    condition under the policy, BGI will instruct PMC to top up the guarantee for the entire duration of your treatment in
    the hospital, subject to the benefits limits.
5. PMC and BGI will manage your discharge planning including the settlement of all valid medical bills.  Any ineligible
    or excess expenses not covered are to be settled by you.

B) Emergency Hospital Admission                                                            
     PMC is obligated to provide you with the initial Guaranteed Letter in the event of emergency treatment.

3 Is there any criteria of Pre-Certification?      Yes

a) the condition requiring treatment is a Covered Condition
b) the condition does not fall within the Exclusions/Limitations of the policy

When Pre-Certification is completed, we will provide
a) Letter of Guarantee for admission
b) Upon discharge, BGI will settle your validated medical bills, however all ineligible or excess expenses must be paid
    by you upon discharge.
 
4 What if Pre-Certification fails?
Diagnosis may not be easily ascertainable or your condition requiring treatment may not be covered under the Policy, your may have to pay for your own treatment and seek reimbursement from BGI after dischage.
 
5 Can I cover my child?
Yes, provided you or your spouse must be the Insured Policyholder.                                       

6 Is there a waiting period?
Yes, 30 days except for accidental injuries.
 
7 When can the policy be effected?
Upon acceptance by the Company and premium dully paid.
 
8 What is the role of the Managed Care Organization ( MCO )?
They are the administrator of the plan and administer pre-certification of hospital admission.  They also provide the  helpline for medical advice and related services.  AIA has set up her own department to handle this in 2002 due to various problems faced by her policyholders. 
 
9 Does take-over condition applies for B-Health Wise/Elite to shift over?
Yes, we will apply the take-over condition subject to terms and condition and acceptance by the company.
 
10 How about Take Over from Other Insurer Health Plan?
A copy of the policy is required to be enclosed before we could consider to give the take-over condition.
 
11 For Family Plan how many spouses and children are allowed?
Only 1 legally nominated spouse and all children as defined are eligible for coverage.                 

12 Is RM2,500 the limit for Guarantee Letter for Hospital admission by MCO?
Yes, it is regulated.
 
13 Who is responsible to pay the ineligible expenses upon discharge?
The patient has to pay.
 
14 Is there a restriction of panel of hospitals by Pantai Medicare ( PMC )?
No, this facility is recognised by most major participating hospitals in Malaysia.
 
15 Is Oversea Treatment eligible for Pre-Certification?
No, this is only applicable for disability diagnosed in Malaysia and for oversea treatment, they had to seek reimbursement from BGI after discharge.
 
16 Do claimant has to submit claim form when admission is arranged by Pantai Medicare ( PMC )?
No, PMC is responsible.                                                                                               

17 What is not covered?

1.  Pre-existing conditions existing prior to the effective date of Insurance and Specified Illnesses during the first 12 months of continuous cover of:

 i) Stones in the urinary and biliary systems
ii) Hypertension or cardio-vascular diseases
iii) Cataracts
iv) Tumours of any kind, including cysts
v) Abnormalities of the Nasal Septum/Turbinates/Sinus
vi) Haemorrhoids, fistulae
vii) Gastric and duodenal ulcers
viii) Endometriosis including diseases of the Reproductive System
ix) Tonsils requiring surgery
x) Diabetes mellitus
xi) Hernias of any kind

2.   Any medical or physical conditions arising within the first 30 days of cover except for accidental injuries.

3.  Normal exclusions such as congenital abnormalities, circumcision, cosmetic surgery, drug addiction, intoxication, venereal diseases, AIDS or HIV related diseases, pregnancy and its related gynaecological conditions, erectile dysfunction, self-inflicted injuries, mental illnesses and psychiatric disorders, war or military related activites.
                                                                                                                                  

18 If the Insured is known to have suffered from existing condition before the effective date of the insurance, is it termed as pre-existing and if so when will such coverage of the condition commence?
Yes, condition suffered before the effective date of insurance whether the Insured was aware or should have reasonably been aware is termed as pre-existing condition.
 
The coverage of such condition will commence provided the Insured has not consulted any doctor for the purpose of medical treatment or advice for that condition or any related condition for a continuous period of 12 months.
 
Example:  Insured has Asthma before 01/08/1999 and has been accepted without Exclusion to the disability.