Insights from Prudential’s Medical Insurance Claims Data

Medical insurance is designed to distribute the financial burden of healthcare expenses among a large group of policyholders. The logic is that spreading health costs may greatly reduce the overall financial impact on individuals. In practice, insurance companies typically negotiate rates with healthcare providers, delivering discounted fees for policyholders.

Medical insurance works to protect you and your loved ones in unexpected health emergencies. However, many people in Malaysia are still unaware of its benefits and the risks of inadequate coverage.

In this article, we share insights from Prudential's medical insurance claims data, including

• The sharp increase in medical claims,

• The top five medical illnesses diagnosed by claim type,

• The causes of the rising cost of healthcare, and

• How medical insurance can help you deal with these challenges.

 

 

The sharp increase in medical insurance claims in Malaysia

According to Prudential's latest Claims Payout Data Report, Prudential paid RM2.04 billion in claims in 2022, a 25.9% increase from 2021. From this amount, RM1.46 billion was for medical claims alone, a 33.9% increase from 2021.

This denotes that people increasingly seek medical treatment and rely on medical insurance to cover expenses. However, it also indicates that medical treatment costs are rising.

The report also shows that the number of medical claims increased by 29.2% from the previous year. This indicates that insurance uptake is rising yearly, along with an increase in disease diagnoses.

Moreover, the report reveals that 19.4% of the medical claims were paid to policy holders between 41 to 50 years old .

In 2023, Prudential’s medical claims payout saw a further 30% increase due to higher utilization and medical inflation. The top five diagnoses included breast cancer, cataracts, heart disease, gastritis, and acute gastroenteritis, with breast cancer being the most common condition claimed.

Top 5 medical illnesses diagnoses by claim type in Malaysia

Based on Prudential’s medical insurance claims data, the top five medical illnesses diagnoses by claim type in Malaysia are:

1. Cataract

A cataract is a disorder where the lens of one's eye becomes cloudy and affects their vision. It is among the most ubiquitous causes of vision loss among older people. According to Prudential's claims data,

• Cataracts accounted for RM53,053,000 of total medical claims (RM1.46 billion) in 2022 and RM27,171,180 in 2023.

• The highest medical claims payout for cataracts was RM53,000 in 2022 and RM44,393 in 2023.

• The average claims payout for cataracts was RM9,131 in 2022 and RM4,521.75 in 2023.

 

 

2. Breast cancer

Breast cancer is a unique type of cancer that forms in the breast tissue, presenting as a lump or thickening in the breast. It's the most common cancer among women in Malaysia and worldwide. According to Prudential's claims data,

• Breast cancer accounted for RM53,049,000 of total medical claims in 2022 and RM28,507,916 in 2023. 

• The highest medical claims payout for breast cancer was RM517,000 and RM412,574 in 2023.

• The average claims payout for breast cancer was RM35,202 and RM5,364.68 in 2023.

 

 

3. Ischemic heart disease

Ischemic heart disease, typically called coronary artery disease, is a leading cause of mortality worldwide. Prudential’s 2022 claims data indicates a substantial number of cases related to ischemic heart disease, emphasising the importance of medical insurance coverage for cardiac-related conditions. According to the data,

• Ischemic heart disease accounted for RM45,010,000 of total medical claims in 2022 and RM24,804,947 in 2023. 

• The highest medical claims payout for this condition was RM195,000 and RM147,634 in 2023.

• The average claim size for ischemic heart disease was RM18,739 and RM 9214.32 in 2023.

 

 

4. Gastritis

Gastritis is a unique condition where the stomach lining becomes inflamed and irritated. It may cause abdominal pain, nausea, stomach irritation, vomiting, or bleeding.

Gastritis may be triggered by excessive alcohol consumption, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), stress, and autoimmune disorders. According to Prudential's 2022 claims data,

• Gastritis accounted for RM40,274,000 of total medical claims in 2022 and RM21,391,725 in 2023.

• The highest medical claims payout for gastritis was RM86,000 and RM155,258 in 2023.

• The average claim size for gastritis was RM5,827 and RM 3185.66 in 2023.

 

 

Fortunately, medical insurance coverage ensures that individuals receive appropriate medical attention, including consultations, diagnostic tests, and medications, to alleviate gastritis symptoms and restore their health.

Acute gastroenteritis

Acute gastroenteritis is when parasites, viruses, or bacteria infect the stomach and intestines. It may cause diarrhoea, vomiting, fever, abdominal pain, or dehydration. According to Prudential's claims data,

• Acute gastroenteritis accounted for RM27,595,000 of total medical claims in 2022 and RM17,220,647 in 2023.

• The highest medical claims payout for acute gastroenteritis was RM102,000 and RM58,030 in 2023.

• The average claims payout for this condition was RM4,927 and RM 2815.67 in 2023.

 

 

Why is healthcare cost increasing in Malaysia?

The rise in the cost of healthcare, also known as medical inflation, is due to several factors. Understanding them is essential to comprehending the significance of medical insurance coverage. Several factors contribute to this upward trend:

Increase in chronic illnesses

The prevalence of chronic diseases, like diabetes, hypertension, and heart disease, is rising in Malaysia. These conditions require ongoing management and specialised care, leading to higher healthcare expenses.

Medical insurance coverage is crucial in supporting individuals with chronic illnesses by providing access to regular check-ups, medications, and specialist consultations.

Increase in outpatient and emergency room costs

The cost of outpatient treatments and emergency room visits has also notably increased. However, whether routine medical check-ups or unexpected medical emergencies, medical insurance offers financial protection, covering the expenses associated with consultations, diagnostic tests, medications, and hospitalisation if necessary.

Rising medical insurance premiums

Escalating healthcare costs have a direct impact on medical insurance premiums. As medical treatments become more advanced and expensive, insurance providers must adjust their premiums accordingly to ensure they can continue providing comprehensive coverage to policyholders.

While premiums may increase over time, weighing this against the potential financial burden of uncovered medical expenses is crucial.

Higher out-of-pocket costs

Without adequate medical insurance coverage, individuals may bear a substantial portion of their healthcare expenses out-of-pocket. These costs can quickly accumulate, potentially causing financial strain.

By securing comprehensive medical insurance, individuals can protect themselves from high out-of-pocket expenses and focus instead on their recovery.

Patients avoiding or postponing care

Because medical care can be costly, individuals with health issues may also postpone or avoid going to the doctor until they think it is necessary. Delaying essential treatments or check-ups can lead to the worsening of existing illnesses or the development of new complications.

Medical insurance coverage encourages individuals to seek timely medical attention without worrying about the associated costs, ultimately safeguarding their health and well-being.

New and costlier technology

Advancements in medical technology have undoubtedly revolutionised healthcare, allowing for more accurate diagnoses and improved treatment options. However, these innovations often come with a higher price tag to make up for the years of rigorous Research & Development (R&D) investment that biotechnology companies have undertaken.

Medical insurance coverage ensures that individuals can access these cutting-edge technologies without bearing the full financial burden, enabling them to benefit from the latest medical advancements.

How can medical insurance help?

Medical insurance largely operates on the concept of risk pooling. With this concept, healthy individuals contribute to a financial pool alongside individuals with higher healthcare needs to mitigate the financial risks associated with healthcare expenses.

Thus, medical insurance helps with the increasing healthcare costs by providing financial protection and peace of mind. This is because it covers some or all of one's medical expenses, depending on their plan type and benefits. In addition, medical insurance can also offer other benefits such as cashless admission, hospital income, overseas coverage, and wellness rewards.

Additionally, because insurance companies negotiate with healthcare providers via contracts to secure lower rates for medical services and treatments, policyholders inadvertently benefit from cost control and reasonable medical pricing.

Prudential medical insurance

Malaysia's leading insurance provider, Prudential, offers comprehensive medical insurance plans tailored to the requirements of each individual. The medical insurance plans come with a variety of advantages, including:

• Coverage for hospitalisation expenses, including room charges, surgical fees, and medications.

• Outpatient benefits for consultations, diagnostic tests, and prescribed medications.

• Specialist consultations and treatments for specific conditions.

• Coverage for critical illnesses, providing financial support during challenging times.

• Additional benefits such as maternity coverage, wellness programmes.

 

 

By investing in Prudential's medical insurance plans, individuals can proactively protect themselves and their families from the financial burdens associated with healthcare expenses. These plans offer peace of mind, knowing that adequate coverage is in place, allowing individuals to focus on their health and well-being.

FAQ

What is medical claims data?

Medical claims data refer to the detailed records of medical services provided to insured individuals, including diagnoses, treatments, and costs.

Why is medical claims data important?

Medical claims data is vital as it helps insurers analyze healthcare trends, manage costs, and improve the quality of care. By understanding these trends, insurers can develop better policies, negotiate with healthcare providers, and enhance patient care strategies.

What are the benefits of analyzing medical claims data?

Analyzing medical claims data offers several benefits, including identifying common health issues, improving policy coverage, and optimizing healthcare costs. This analysis helps insurers make informed decisions about policy changes and cost management.

Can patients access their medical claims data?

Yes, patients can access their medical claims data. They can request this information from their insurance provider, which is required to provide details of the services covered and the costs incurred.

How does medical claims data help in policy planning?

Medical claims data helps in policy planning by providing insights into the frequency and cost of various medical conditions. Insurers use this data to design policies that better meet the needs of their customers and to ensure adequate coverage for prevalent health issues.

What types of information are included in medical claims data?

Medical claims data includes patient demographics, diagnosis codes, treatment details, service dates, and costs. This comprehensive data set allows insurers to analyze and manage healthcare services effectively.

How secure are medical claims data?

Medical claims data is highly secure. Insurers use robust security measures, including encryption and access controls, to protect patient information and ensure privacy. Compliance with data protection regulations is also strictly maintained.

How can medical claims data reduce healthcare costs?

Medical claims data can reduce healthcare costs by identifying inefficiencies and high-cost areas. Insurers can use this data to implement cost-saving measures, negotiate better rates with providers, and promote preventive care programs.

How does medical claims data improve patient care?

Medical claims data improves patient care by enabling better disease management programs and personalized care plans. By analyzing claims data, insurers can identify trends and patterns that lead to improved health outcomes and more effective treatments.

How to make health insurance claims during medical emergencies?

In an emergency, contact your insurance provider immediately, provide the necessary medical documents, and follow their specific claims processing steps.

Can an employee claim medical expenses in Malaysia?

Employees in Malaysia can claim medical expenses if their employer provides medical insurance benefits.

What are the steps for an insurance claim?

To file an insurance claim, first review your policy to understand your coverage. Notify your insurance provider about the incident, then obtain and complete the required claim forms, gathering all necessary documentation. Submit the completed forms and documents online, by mail, or through your agent. Follow up with your insurance provider using your claim reference number. They will process and review your claim, and you will receive a decision. If the claim is denied, you can appeal by providing additional information. For detailed guidance on insurance claims with Prudential, contact us and speak to our team.

When to claim insurance?

You should claim insurance when you experience an event covered by your policy, such as medical treatments, vehicle accidents, property damage, or the death of the insured. For further information on the claim process and guidance, consult your policy or contact your insurance provider.

What is an example of a health claim?

An example of a health claim is when you visit a doctor for a medical condition, and the expenses for the consultation, tests, admissions and medications are submitted to your health insurance company for reimbursement.

What is the medical expense policy?

A medical expense policy is a health insurance plan that covers the costs of various healthcare services, such as doctor visits, hospital stays, surgeries, and medications. Coverage details, including what is covered, deductibles, co-pays, and out-of-pocket maximums, vary by policy. These policies help policyholders manage medical expenses and ensure access to necessary healthcare services.

Conclusion

In conclusion, the insights from Prudential's medical insurance claims data provide valuable knowledge about the importance of medical insurance in Malaysia. With the rise in medical illnesses and healthcare costs, having comprehensive coverage is crucial for individuals to secure their financial well-being and access quality healthcare services.

And by investing in reputable medical insurance plans, such as those offered by Prudential, individuals gain peace of mind, knowing that their health and financial stability are protected. Remember, it's always smarter to be prepared and insured than to face unforeseen medical expenses without support.