Claim Rejected, Then Partly Paid: How a Medical Review Changed a Gallstone Case

A Claim Rejected Under Several Policy Provisions

In a case published by Malaysia's Financial Markets Ombudsman Service (FMOS), a claimant identified by the pseudonym “Raju” was admitted to Institut Kanser Negara with superobesity, metabolic syndrome, mechanical issues and gallstones. He claimed Daily Hospital Income and Surgical Benefits.

The insurer rejected the claim by relying on the policy's 30-day waiting period, its specified-illness provision and an exclusion concerning weight-loss treatment. At first glance, several parts of the admission appeared to support that decision.

What the Medical Records Showed

Raju's superobesity, metabolic syndrome and mechanical issues had been diagnosed during the 30-day waiting period. The gallstones, however, were found later through an ultrasound of the hepatobiliary system—after both the 30-day waiting period and the 120-day specified-illness period referred to in the case.

FMOS also noted that the treating doctor had not stated that the gallstones were related to Raju's superobesity. They were discovered incidentally during investigation. That distinction became central to the review.

The Successful Outcome

After considering the timing and medical evidence, FMOS recommended that the insurer consider paying the part of the claim attributable to the gallstone condition on a prorated basis. The insurer agreed, and the dispute was settled amicably.

This is a genuine positive claim outcome. It shows that a rejection may warrant review when the decision groups together separate diagnoses without sufficient medical support.

Why This Case Succeeded

• The timeline was checked carefully: each diagnosis was compared with the relevant waiting periods.
• The conditions were assessed separately: an excluded or early diagnosis did not automatically determine the status of a later, distinct condition.
• The treating doctor's evidence mattered: the records did not establish the alleged connection between obesity and the gallstones.
• The requested remedy was proportionate: the review focused on the gallstone-related part rather than demanding payment for every aspect of the admission.

What Claimants Can Learn

1. Request the insurer's written reason and the exact policy clauses used.
2. Build a dated medical timeline showing when each symptom, test and diagnosis first appeared.
3. Ask the treating doctor to clarify whether two conditions are medically connected, where appropriate.
4. Request an itemised bill so disputed and potentially payable treatment can be distinguished.
5. Ask for an internal review before escalating an unresolved complaint.

A review is not a guarantee of payment. Its value depends on the policy wording and evidence. But a clear, documented request gives the insurer—and later an independent dispute body—a specific issue to assess.

Where CASB Can Add Value

Good claim support begins before a dispute. An adviser can help a policyholder locate the relevant schedule and clauses, organise the chronology, identify missing documents and phrase questions clearly. The insurer remains responsible for deciding the claim, and FMOS independently handles eligible unresolved disputes.

CASB did not handle Raju's case and does not claim credit for its result. We present it because the official outcome demonstrates the practical value of careful documentation and a focused review.

Source and Important Context

This article is based on the official FMOS “Medical & Hospitalisation – Policy Exclusion” case study. FMOS changed the claimant's name to protect confidentiality. The published summary does not identify the insurer, policy name, claim amount or complete medical file.

The case should not be read as a precedent guaranteeing the same result for another claimant. Medical evidence, dates, benefits, exclusions and policy wording differ between cases.