Is it medically necessary

The insured was admitted and diagnosed with ‘Stroke and Hypertension’. The insurer had approved his hospitalisation claim. However, the charges for his medication for his post-hospitalisation claim was not paid in full by the insurer on the ground that the prescribed medication is not medically necessary for the treatment of the diagnosis and is preventive in nature.

Investigation and findings
The following findings were noted:
(i) The attending doctor of the insured had given an explanation stating that the prescribed medicine was medically necessary to treat the
(ii) A clarification letter from the Ministry of Health, Malaysia (MOH) explained that the prescribed medicine is classified as traditional
medicine, where the efficacy of the medicine is not proven through clinical studies.
(iii) Inconsistent industry practices showed that some paid for the prescribed medicine and some did not.
(iv) The policy does not define what preventive medicine is.

OFS adjudicated the case in favour of insured based on the following grounds:
(i) The MOH has classified the prescribed medicine as traditional medicine, not preventive. The provision referred by the insurer is silent on the use/prescription of traditional medicine and the word ‘preventive’ was not defined in the policy either.
(ii) This creates ambiguity as to whether traditional medicine falls under preventive medicine; the rule of contra proferentum will apply where any doubt or ambiguity should be construed in favour of the insured.
(iii) The insured, being a layperson, relied entirely on his treating doctor’s advice with regards to treatment given and medicine prescribed
especially after having undergone a major life-threatening stroke trauma.
(iv) It is only fair and reasonable for the insurer to reimburse the insured on the prescribed medication.