{"id":9973,"date":"2026-04-29T12:25:21","date_gmt":"2026-04-29T04:25:21","guid":{"rendered":"https:\/\/www.fmos.org.my\/?p=9973"},"modified":"2026-04-29T15:25:58","modified_gmt":"2026-04-29T07:25:58","slug":"congenital-condition-and-policy-exclusion","status":"publish","type":"post","link":"https:\/\/www.fmos.org.my\/bm\/congenital-condition-and-policy-exclusion\/","title":{"rendered":"Keadaan Kongenital dan Pengecualian Polisi"},"content":{"rendered":"<p class=\"wp-block-paragraph\">Casper telah dimasukkan ke hospital akibat sakit dada iskemik dan mengemukakan tuntutan kos rawatan hospital. Penanggung insurans menolak tuntutan tersebut atas alasan bahawa keadaan tersebut diklasifikasikan sebagai anomali kongenital dan oleh itu dikecualikan di bawah Polisi.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong><em>Pengecualian<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Syarikat tidak akan membayar Manfaat Insurans seperti yang dinyatakan dalam Klausa 5.1 di bawah Polisi ini bagi mana-mana perkara berikut, sama ada secara langsung atau tidak langsung:<br><strong>Sebarang rawatan atau pembedahan untuk Keadaan Kongenital<\/strong> atau kecacatan, termasuk keadaan keturunan.<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><em>\u201cKeadaan Kongenital\u201d bermaksud sebarang keabnormalan perubatan atau fizikal yang wujud pada masa kelahiran atau keabnormalan fizikal neonatal yang berkembang dalam tempoh enam (6) bulan dari tarikh kelahiran. Ini termasuk semua jenis hernia dan epilepsi kecuali jika disebabkan oleh trauma yang berlaku selepas Tarikh Kuat Kuasa.<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>PENEMUAN<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Angiogram koronari Casper menunjukkan diagnosis \u201cmyocardial bridge\u201d, iaitu satu anomali koronari. Ia berlaku pada kira-kira 5% individu dan merupakan salah satu punca sakit dada iskemia yang diketahui.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">ICD\u201111 (Kod BA60.0) mengklasifikasikan penyambungan miokardium di bawah anomali arteri koronari, yang diiktiraf secara perubatan sebagai kongenital.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Walaupun keadaan Casper didiagnosis pada usia dewasa, anomali kongenital boleh menunjukkan simptom di kemudian hari. Takrifan dalam Polisi berkaitan dengan kewujudan semasa lahir, bukan masa diagnosis dibuat.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>KEPUTUSAN<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Ombudsman mengakui tahap keseriusan keadaan Casper, akan tetapi bukti perubatan mengesahkan bahawa \"myocardial bridge\" ialah anomali koronari kongenital.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Memandangkan Polisi secara jelas mengecualikan keadaan kongenital tanpa mengira bila simptom muncul, keputusan penanggung insurans untuk menolak tuntutan adalah selaras dengan terma Polisi. Keputusan adjudikasi memihak kepada penanggung insurans.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>","protected":false},"excerpt":{"rendered":"<p>Casper was hospitalised due to ischemic chest pain and submitted a hospitalisation claim for the expenses incurred. The insurer rejected the claim on the grounds that the condition was classified as a congenital anomaly and therefore excluded under the Policy. Exclusions The Company will not pay the Insured Benefits as stated in Clause 5.1 under [&hellip;]<\/p>","protected":false},"author":4,"featured_media":9974,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[25,27],"tags":[],"class_list":["post-9973","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-case-studies","category-insurance-takaful"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.8 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Congenital Condition and Policy 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\/congenital-condition-and-policy-exclusion\/\" \/>\n<meta property=\"og:locale\" content=\"ms_MY\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Congenital Condition and Policy Exclusion - FMOS\" \/>\n<meta property=\"og:description\" content=\"Casper was hospitalised due to ischemic chest pain and submitted a hospitalisation claim for the expenses incurred. The insurer rejected the claim on the grounds that the condition was classified as a congenital anomaly and therefore excluded under the Policy. Exclusions The Company will not pay the Insured Benefits as stated in Clause 5.1 under [&hellip;]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.fmos.org.my\/bm\/congenital-condition-and-policy-exclusion\/\" \/>\n<meta property=\"og:site_name\" content=\"FMOS\" \/>\n<meta property=\"article:published_time\" content=\"2026-04-29T04:25:21+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2026-04-29T07:25:58+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.fmos.org.my\/wp-content\/uploads\/2026\/04\/AR-Case-Studies-16.png\" \/>\n\t<meta property=\"og:image:width\" content=\"500\" \/>\n\t<meta property=\"og:image:height\" content=\"501\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/png\" \/>\n<meta name=\"author\" content=\"commsadmin\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"commsadmin\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"2 minit\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/#article\",\"isPartOf\":{\"@id\":\"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/\"},\"author\":{\"name\":\"commsadmin\",\"@id\":\"https:\/\/www.fmos.org.my\/en\/#\/schema\/person\/8fbea4ebb5130d485f32d0731efd4689\"},\"headline\":\"Congenital Condition and Policy Exclusion\",\"datePublished\":\"2026-04-29T04:25:21+00:00\",\"dateModified\":\"2026-04-29T07:25:58+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/\"},\"wordCount\":267,\"publisher\":{\"@id\":\"https:\/\/www.fmos.org.my\/en\/#organization\"},\"image\":{\"@id\":\"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/#primaryimage\"},\"thumbnailUrl\":\"https:\/\/www.fmos.org.my\/wp-content\/uploads\/2026\/04\/AR-Case-Studies-16.png\",\"articleSection\":[\"Case Studies\",\"Insurance\/ Takaful\"],\"inLanguage\":\"ms-MY\"},{\"@type\":\"WebPage\",\"@id\":\"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/\",\"url\":\"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/\",\"name\":\"Congenital Condition and Policy Exclusion - FMOS\",\"isPartOf\":{\"@id\":\"https:\/\/www.fmos.org.my\/en\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/#primaryimage\"},\"image\":{\"@id\":\"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/#primaryimage\"},\"thumbnailUrl\":\"https:\/\/www.fmos.org.my\/wp-content\/uploads\/2026\/04\/AR-Case-Studies-16.png\",\"datePublished\":\"2026-04-29T04:25:21+00:00\",\"dateModified\":\"2026-04-29T07:25:58+00:00\",\"breadcrumb\":{\"@id\":\"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/#breadcrumb\"},\"inLanguage\":\"ms-MY\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/\"]}]},{\"@type\":\"ImageObject\",\"inLanguage\":\"ms-MY\",\"@id\":\"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/#primaryimage\",\"url\":\"https:\/\/www.fmos.org.my\/wp-content\/uploads\/2026\/04\/AR-Case-Studies-16.png\",\"contentUrl\":\"https:\/\/www.fmos.org.my\/wp-content\/uploads\/2026\/04\/AR-Case-Studies-16.png\",\"width\":500,\"height\":501},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/www.fmos.org.my\/en\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Congenital Condition and Policy Exclusion\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/www.fmos.org.my\/en\/#website\",\"url\":\"https:\/\/www.fmos.org.my\/en\/\",\"name\":\"FMOS\",\"description\":\"\",\"publisher\":{\"@id\":\"https:\/\/www.fmos.org.my\/en\/#organization\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/www.fmos.org.my\/en\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"ms-MY\"},{\"@type\":\"Organization\",\"@id\":\"https:\/\/www.fmos.org.my\/en\/#organization\",\"name\":\"FMOS\",\"alternateName\":\"Financial Markets Ombudsman Services\",\"url\":\"https:\/\/www.fmos.org.my\/en\/\",\"logo\":{\"@type\":\"ImageObject\",\"inLanguage\":\"ms-MY\",\"@id\":\"https:\/\/www.fmos.org.my\/en\/#\/schema\/logo\/image\/\",\"url\":\"https:\/\/www.fmos.org.my\/wp-content\/uploads\/2026\/04\/FMOS_hori-logo_fullcolor-Custom.png\",\"contentUrl\":\"https:\/\/www.fmos.org.my\/wp-content\/uploads\/2026\/04\/FMOS_hori-logo_fullcolor-Custom.png\",\"width\":262,\"height\":50,\"caption\":\"FMOS\"},\"image\":{\"@id\":\"https:\/\/www.fmos.org.my\/en\/#\/schema\/logo\/image\/\"}},{\"@type\":\"Person\",\"@id\":\"https:\/\/www.fmos.org.my\/en\/#\/schema\/person\/8fbea4ebb5130d485f32d0731efd4689\",\"name\":\"commsadmin\",\"image\":{\"@type\":\"ImageObject\",\"inLanguage\":\"ms-MY\",\"@id\":\"https:\/\/www.fmos.org.my\/en\/#\/schema\/person\/image\/\",\"url\":\"https:\/\/secure.gravatar.com\/avatar\/a05f4bcfd9343a8f8d132e42c78c8681f5478a61135065e2d36ad22020b81651?s=96&d=mm&r=g\",\"contentUrl\":\"https:\/\/secure.gravatar.com\/avatar\/a05f4bcfd9343a8f8d132e42c78c8681f5478a61135065e2d36ad22020b81651?s=96&d=mm&r=g\",\"caption\":\"commsadmin\"},\"url\":\"https:\/\/www.fmos.org.my\/bm\/author\/commsadmin\/\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Congenital Condition and Policy Exclusion - FMOS","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/www.fmos.org.my\/bm\/congenital-condition-and-policy-exclusion\/","og_locale":"ms_MY","og_type":"article","og_title":"Congenital Condition and Policy Exclusion - FMOS","og_description":"Casper was hospitalised due to ischemic chest pain and submitted a hospitalisation claim for the expenses incurred. The insurer rejected the claim on the grounds that the condition was classified as a congenital anomaly and therefore excluded under the Policy. Exclusions The Company will not pay the Insured Benefits as stated in Clause 5.1 under [&hellip;]","og_url":"https:\/\/www.fmos.org.my\/bm\/congenital-condition-and-policy-exclusion\/","og_site_name":"FMOS","article_published_time":"2026-04-29T04:25:21+00:00","article_modified_time":"2026-04-29T07:25:58+00:00","og_image":[{"width":500,"height":501,"url":"https:\/\/www.fmos.org.my\/wp-content\/uploads\/2026\/04\/AR-Case-Studies-16.png","type":"image\/png"}],"author":"commsadmin","twitter_card":"summary_large_image","twitter_misc":{"Written by":"commsadmin","Est. reading time":"2 minit"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"Article","@id":"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/#article","isPartOf":{"@id":"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/"},"author":{"name":"commsadmin","@id":"https:\/\/www.fmos.org.my\/en\/#\/schema\/person\/8fbea4ebb5130d485f32d0731efd4689"},"headline":"Congenital Condition and Policy Exclusion","datePublished":"2026-04-29T04:25:21+00:00","dateModified":"2026-04-29T07:25:58+00:00","mainEntityOfPage":{"@id":"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/"},"wordCount":267,"publisher":{"@id":"https:\/\/www.fmos.org.my\/en\/#organization"},"image":{"@id":"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/#primaryimage"},"thumbnailUrl":"https:\/\/www.fmos.org.my\/wp-content\/uploads\/2026\/04\/AR-Case-Studies-16.png","articleSection":["Case Studies","Insurance\/ Takaful"],"inLanguage":"ms-MY"},{"@type":"WebPage","@id":"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/","url":"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/","name":"Congenital Condition and Policy Exclusion - FMOS","isPartOf":{"@id":"https:\/\/www.fmos.org.my\/en\/#website"},"primaryImageOfPage":{"@id":"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/#primaryimage"},"image":{"@id":"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/#primaryimage"},"thumbnailUrl":"https:\/\/www.fmos.org.my\/wp-content\/uploads\/2026\/04\/AR-Case-Studies-16.png","datePublished":"2026-04-29T04:25:21+00:00","dateModified":"2026-04-29T07:25:58+00:00","breadcrumb":{"@id":"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/#breadcrumb"},"inLanguage":"ms-MY","potentialAction":[{"@type":"ReadAction","target":["https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/"]}]},{"@type":"ImageObject","inLanguage":"ms-MY","@id":"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/#primaryimage","url":"https:\/\/www.fmos.org.my\/wp-content\/uploads\/2026\/04\/AR-Case-Studies-16.png","contentUrl":"https:\/\/www.fmos.org.my\/wp-content\/uploads\/2026\/04\/AR-Case-Studies-16.png","width":500,"height":501},{"@type":"BreadcrumbList","@id":"https:\/\/www.fmos.org.my\/congenital-condition-and-policy-exclusion\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/www.fmos.org.my\/en\/"},{"@type":"ListItem","position":2,"name":"Congenital Condition and Policy Exclusion"}]},{"@type":"WebSite","@id":"https:\/\/www.fmos.org.my\/en\/#website","url":"https:\/\/www.fmos.org.my\/en\/","name":"FMOS","description":"","publisher":{"@id":"https:\/\/www.fmos.org.my\/en\/#organization"},"potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/www.fmos.org.my\/en\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"ms-MY"},{"@type":"Organization","@id":"https:\/\/www.fmos.org.my\/en\/#organization","name":"FMOS","alternateName":"Financial Markets Ombudsman Services","url":"https:\/\/www.fmos.org.my\/en\/","logo":{"@type":"ImageObject","inLanguage":"ms-MY","@id":"https:\/\/www.fmos.org.my\/en\/#\/schema\/logo\/image\/","url":"https:\/\/www.fmos.org.my\/wp-content\/uploads\/2026\/04\/FMOS_hori-logo_fullcolor-Custom.png","contentUrl":"https:\/\/www.fmos.org.my\/wp-content\/uploads\/2026\/04\/FMOS_hori-logo_fullcolor-Custom.png","width":262,"height":50,"caption":"FMOS"},"image":{"@id":"https:\/\/www.fmos.org.my\/en\/#\/schema\/logo\/image\/"}},{"@type":"Person","@id":"https:\/\/www.fmos.org.my\/en\/#\/schema\/person\/8fbea4ebb5130d485f32d0731efd4689","name":"commsadmin","image":{"@type":"ImageObject","inLanguage":"ms-MY","@id":"https:\/\/www.fmos.org.my\/en\/#\/schema\/person\/image\/","url":"https:\/\/secure.gravatar.com\/avatar\/a05f4bcfd9343a8f8d132e42c78c8681f5478a61135065e2d36ad22020b81651?s=96&d=mm&r=g","contentUrl":"https:\/\/secure.gravatar.com\/avatar\/a05f4bcfd9343a8f8d132e42c78c8681f5478a61135065e2d36ad22020b81651?s=96&d=mm&r=g","caption":"commsadmin"},"url":"https:\/\/www.fmos.org.my\/bm\/author\/commsadmin\/"}]}},"_links":{"self":[{"href":"https:\/\/www.fmos.org.my\/bm\/wp-json\/wp\/v2\/posts\/9973","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.fmos.org.my\/bm\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.fmos.org.my\/bm\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.fmos.org.my\/bm\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.fmos.org.my\/bm\/wp-json\/wp\/v2\/comments?post=9973"}],"version-history":[{"count":2,"href":"https:\/\/www.fmos.org.my\/bm\/wp-json\/wp\/v2\/posts\/9973\/revisions"}],"predecessor-version":[{"id":10019,"href":"https:\/\/www.fmos.org.my\/bm\/wp-json\/wp\/v2\/posts\/9973\/revisions\/10019"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.fmos.org.my\/bm\/wp-json\/wp\/v2\/media\/9974"}],"wp:attachment":[{"href":"https:\/\/www.fmos.org.my\/bm\/wp-json\/wp\/v2\/media?parent=9973"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.fmos.org.my\/bm\/wp-json\/wp\/v2\/categories?post=9973"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.fmos.org.my\/bm\/wp-json\/wp\/v2\/tags?post=9973"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}