{"id":5587,"date":"2025-03-27T04:39:10","date_gmt":"2025-03-27T04:39:10","guid":{"rendered":"https:\/\/fmos.org.my\/?p=5587"},"modified":"2026-04-29T15:43:02","modified_gmt":"2026-04-29T07:43:02","slug":"medical-hospitalisation-cancer-claim-exclusion","status":"publish","type":"post","link":"https:\/\/www.fmos.org.my\/bm\/medical-hospitalisation-cancer-claim-exclusion\/","title":{"rendered":"Perubatan &amp; Kemasukan ke Hospital \u2013 Pengecualian Tuntutan Kanser"},"content":{"rendered":"<p class=\"wp-block-paragraph\">Encik Lim telah disahkan menghidap penyakit Kanser Esofagus tahap lanjut yang telah merebak ke bahagian kanan muka dan otot lengan kanannya. Doktornya telah mencadangkan rawatan kemoterapi yang digabungkan dengan imunoterapi bagi menghalang kanser daripada menjadi lebih teruk.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Pihak penanggung insurans telah menanggung perbelanjaan perubatan beliau namun telah mengecualikan caj untuk Rawatan Imunoterapi berdasarkan peruntukan polisi berikut:<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><em>\u201816. Rawatan Kanser Pesakit Luar Tahunan (Hanya Bayaran Balik)\nSekiranya Orang Yang Diinsuranskan disahkan menghidap Kanser seperti yang ditakrifkan di bawah, Syarikat akan membayar balik Caj Munasabah dan Lazim yang ditanggung bagi rawatan kanser yang Diperlukan Secara Perubatan dan dijalankan di pusat rawatan kanser yang berdaftar secara sah tertakluk kepada had hilang upaya ini seperti yang dinyatakan dalam Jadual Manfaat. Rawatan tersebut (radioterapi atau kemoterapi tidak termasuk konsultasi, ujian pemeriksaan, ubat untuk dibawa pulang) mesti diterima di jabatan pesakit luar Hospital atau pusat rawatan kanser berdaftar sejurus selepas discaj dari kemasukan Hospital atau pembedahan.\u2019<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>PENEMUAN<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Doktor yang merawat Encik Lim telah mengesahkan bahawa imunoterapi bersama dengan kemoterapi adalah rejim rawatan yang penting dan perlu dari segi rawatan. Perkataan \u2018sebegitu\u2019 dalam peruntukan itu bermaksud ia tidak terhad kepada radioterapi dan kemoterapi sahaja.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Polisi hendaklah menyatakan dengan jelas sama ada syarikat insurans berhasrat untuk mengecualikan rawatan imunoterapi. Mengikut Prinsip Contra Proferentem, sebarang kekaburan dalam polisi mesti ditafsirkan memihak kepada pihak yang diinsuranskan.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Syarikat insurans tertentu melindungi rawatan imunoterapi walaupun menggunakan bahasa yang sama dalam peruntukan polisi mereka. Imunoterapi diluluskan oleh FDA dan berdaftar dengan Kementerian Kesihatan Malaysia. Ia menggunakan sistem imun pesakit untuk melawan kanser sama ada dengan mengaktifkan atau menekannya.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Encik Lim, yang merupakan orang awam dan disahkan menghidap penyakit terminal, tidak sepatutnya dihukum kerana mematuhi rawatan yang dinasihatkan oleh doktornya.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>KEPUTUSAN<\/strong> <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Berdasarkan sebab di atas, Ombudsman memutuskan bahawa adalah adil dan munasabah bagi syarikat insurans untuk menampung kos imunoterapi sebagai sebahagian daripada rawatan kanser Encik Lim.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>","protected":false},"excerpt":{"rendered":"<p>Mr Lim was diagnosed with advanced Oesophageal Cancer that had spread to his right face and right arm muscles. His doctor recommended chemotherapy combined with immunotherapy treatment to prevent the cancer from getting worse. The insurer honoured his medical expenses but excluded charges for Immunotherapy Treatment based on the following policy provision: \u201816. Annual OutPatient [&hellip;]<\/p>","protected":false},"author":1,"featured_media":5425,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[25,27],"tags":[31],"class_list":["post-5587","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-case-studies","category-insurance-takaful","tag-insurance"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.8 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Medical &amp; Hospitalisation - Cancer Claim Exclusion - FMOS<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.fmos.org.my\/bm\/medical-hospitalisation-cancer-claim-exclusion\/\" \/>\n<meta property=\"og:locale\" content=\"ms_MY\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Medical &amp; Hospitalisation - Cancer Claim Exclusion - FMOS\" \/>\n<meta property=\"og:description\" content=\"Mr Lim was diagnosed with advanced Oesophageal Cancer that had spread to his right face and right arm muscles. 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