Etiqa Insurance Claim Denied in Malaysia: How to Appeal

Etiqa Insurance Claim Denied in Malaysia: How to Appeal

Etiqa Insurance Berhad and Etiqa Takaful Berhad are subsidiaries of Maybank Group — Malaysia's largest bank — making Etiqa one of the country's largest and most recognised insurance and takaful brands. Etiqa offers both conventional insurance and Islamic takaful products across medical and health, life insurance, motor, property, travel, and personal accident categories.

If Etiqa has denied your insurance or takaful claim in Malaysia, this guide explains your rights and the steps to challenge the decision.

About Etiqa

Etiqa's main protection products include:

• Etiqa Medical Shield / OmniProtect — medical and health insurance (hospitalisation cover)
• Etiqa LifeProtect — life insurance (term, whole life)
• Critical illness riders — attached to life policies
• Takaful products — Islamic insurance alternatives under Etiqa Takaful Berhad
• Motor Takaful / Motor Insurance — vehicle protection
• Travel insurance / takaful
• Personal accident insurance

The complaints and appeal process is similar for both Etiqa Insurance (conventional) and Etiqa Takaful (Islamic).

Common Etiqa Denial Reasons

Medical / hospitalisation claim denials:

• Pre-existing conditions: Etiqa may allege non-disclosure of pre-existing conditions at application.
• Excluded conditions: Congenital conditions, cosmetic procedures, self-inflicted injuries, and HIV/AIDS are typically excluded.
• No Letter of Guarantee (LOG): For planned hospitalisation, Etiqa requires an LOG. Claims without an LOG may be denied or reduced.
• Panel hospital requirements: Some Etiqa medical plans require treatment at panel hospitals. Non-panel treatment may result in reduced coverage.
• Not medically necessary: Etiqa's medical team may dispute clinical necessity.
• Missing documentation: Incomplete claim submissions (missing hospital discharge summary, itemised bills, doctor's reports) cause administrative denials.

Life and critical illness denials:

• Non-disclosure of material facts: Etiqa may allege failure to disclose health history, smoking status, or occupation risk at application.
• CI definition not met: Etiqa's critical illness riders use specific clinical definitions. Disputes arise about whether the diagnosis meets the exact criteria.
• Waiting period: Most CI riders have a 60–90 day waiting period from commencement.
• Policy lapse: If premiums were not paid and the policy lapsed before the claim, Etiqa will deny the claim.

Motor / property / travel denials:

• Disputed liability or cause of accident
• Policy exclusions (driving without valid license, under influence)
• Documentation deficiencies

Your Malaysian Rights When Etiqa Denies a Claim

BNM regulation: Both Etiqa Insurance Berhad and Etiqa Takaful Berhad are licensed and regulated by Bank Negara Malaysia (BNM).

Ombudsman for Financial Services (OFS): Independent dispute resolution for claims up to RM 250,000. Free for consumers; decisions are binding on Etiqa.

BNMLINK: BNM's complaint channels for regulatory issues with licensed insurers.

Shariah Advisory Council: For takaful disputes involving Shariah compliance, the Shariah Advisory Council of BNM provides authoritative rulings.

Step-by-Step: How to Appeal an Etiqa Denial

Step 1: Get the Written Denial

Ensure you have Etiqa's written denial letter specifying:

• The denial reason
• The policy clause or exclusion applied
• Your right to complain

Step 2: Review Your Etiqa Policy Document

Access your policy document through the Etiqa member portal (etiqa.com.my) or contact your agent. Focus on:

• Coverage terms and exclusions relevant to your claim
• CI definitions (for critical illness disputes)
• Pre-existing condition exclusion provisions
• Claims submission requirements

Step 3: Gather Supporting Evidence

For medical claims:

• Hospital discharge summary and itemised bill
• Doctor's letter confirming diagnosis and medical necessity
• Attending doctor's report (ADR) — a standard form Etiqa may require
• LOG approval documentation or evidence of emergency admission

For critical illness claims:

• Specialist's letter specifically addressing Etiqa's policy definition for the claimed condition
• Biopsy, ECG, MRI, or other diagnostic reports
• Medical records from the time of diagnosis

For non-disclosure disputes:

• GP records showing no diagnosis or symptoms before policy application
• GP/specialist letter confirming what you knew at application

Step 4: File a Formal Complaint with Etiqa

Etiqa Customer Service:

• Phone: 1300 13 8888
• Email: customer.care@etiqa.com.my
• Online: etiqa.com.my/contact
• Chat: Etiqa website or Etiqa Connect app
• Post: Etiqa Insurance Berhad / Etiqa Takaful Berhad, Menara Maybank, 100 Jalan Tun Perak, 50050 Kuala Lumpur

State clearly this is a formal complaint against the claim denial. Provide:

• Policy number and claim reference
• Your appeal letter addressing the denial reasons
• All supporting documentation

Step 5: Escalate to the Ombudsman for Financial Services (OFS)

If Etiqa does not resolve the complaint within 60 days or issues an unsatisfactory final response:

OFS Malaysia:

• Online: ofs.org.my
• Phone: 03-2272 2811
• Email: enquiry@ofs.org.my
• Jurisdiction: Disputes up to RM 250,000
• Free for consumers; binding on Etiqa

Step 6: Report to Bank Negara Malaysia (BNM)

For regulatory misconduct concerns:

• BNMLINK: 1-300-88-5465 or bnmlink@bnm.gov.my
• File through BNM's consumer portal at bnm.gov.my

Etiqa-Specific Tips

Etiqa's Maybank relationship: Etiqa being part of Maybank Group means if you are also a Maybank customer, you can sometimes escalate through Maybank's customer service channels, which may have additional internal escalation pathways.

Etiqa Connect App: Etiqa's app allows claim submission, status tracking, and communication with customer service. Use it to document all interactions.

LOG application: Etiqa's LOG (Letter of Guarantee) for hospitalisation can be requested through the Etiqa Connect App or by calling 1300 13 8888. Always request this at least 3 days before planned admission.

Takaful-specific rights: For takaful products, the Islamic insurance contract (Takaful certificate) may be governed by additional Shariah principles. If you believe Etiqa's decision violates Shariah principles, raise this specifically and request a Shariah review.

Non-disclosure after 2 years: As with other Malaysian life insurers, Etiqa's right to avoid a life insurance policy based on innocent non-disclosure typically lapses after 2 years of continuous coverage. If your policy is over 2 years old and the denial involves innocent non-disclosure, raise this limitation explicitly.

Motor claims — police report: For motor insurance claims, ensure you have filed a police report within 24 hours of the accident. Failure to file a timely police report can be used to deny motor claims.

Conclusion

Etiqa's claim denials — particularly for medical pre-existing conditions and critical illness definitions — are regularly challenged through the OFS dispute resolution process. The OFS is free, accessible, and binding on Etiqa. Don't accept a denial without filing a formal complaint and escalating to the OFS if needed. Use ClaimBack at claimback.app to generate a professional appeal letter for your Etiqa Malaysia insurance dispute.

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Related Reading:

• Manulife Malaysia Claim Denied: How to Appeal
• Takaful Malaysia Claim Denied: How to Appeal
• Sun Life Malaysia Claim Denied: How to Appeal
• How to Write an Insurance Demand Letter