【Claim Insurance】A Complete Breakdown of Claim Procedures and Important Documents — 6 Things You Must Know

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1. Why is it so difficult to claim medical insurance?

The first common reason is that at the time of application, the client did not proactively disclose “material facts” (material facts), for example failing to report past medical history, which can render the policy void or result in a claim being denied. It is worth mentioning that if the client applied through an insurance advisor, the advisor also has a responsibility to remind the client to disclose material facts and the serious consequences that non-disclosure may cause.

The second is that the relevant medical expenses involve exclusions, for example medical service costs arising from drug overdose, intentional self-harm, participation in illegal activities, or sexually transmitted diseases. In addition, some older health insurance plans may not cover day-hospital or outpatient surgeries.

Also, medical insurance only reimburses medical expenses that arise from medical necessity (medically necessary), but whether an item is deemed medically necessary is decided by the insurance company. For example, breast reconstruction surgery after mastectomy is not directly classified as medically necessary by every insurer.

Therefore, before hospital admission, clients should first consult their insurance advisor to check whether the item is within the scope of coverage. Some products even offer pre-admission assessment services that can evaluate the treatment fee quotations provided by doctors to avoid disputes.

2. Claim period — how long will it take to receive the money?

The time limit for medical insurance claims is usually 30 to 90 days after discharge or surgery, depending on the insurer's policy.

After receiving the documents, the insurer will conduct a review and approval. Insurers are generally stricter with claims made within two to three years after the policy is taken out (i.e., early claims) and may request the patient's medical records from the Hospital Authority or relevant medical institutions, so the payout can take at least 8 to 12 weeks. As for non-early claims, these are usually processed within about 4 weeks.

3. List of documents required for a claim?

If the policyholder wishes to claim inpatient medical expenses, they must submit the claim form and supporting documents within the specified date, which generally include:

1. Claim form (part of which must be completed by the attending physician and bear the hospital stamp).

2. Original medical receipts and invoices.

3. Laboratory, ultrasound, X‑ray, CT scan, MRI and pathology reports.

4. Referral letter from the doctor or hospital.

5. Copies of the policyholder’s and the insured person’s Hong Kong identity cards.

If the policyholder intends to claim from more than one insurer, they must prepare the claim form of the other insurer, which likewise requires parts to be completed by the attending physician and to bear the hospital stamp.

In addition, when claiming from the first insurer, the policyholder must request from that insurer the return of the original medical receipts or certified copies thereof, and a copy of the first insurer’s settlement/claim details, so that they can apply to the other insurer for a claim.

4. Does "discharge without settling the bill" require prior approval?

Many medical insurance plans claim to offer a "cashless discharge" service, allowing patients to only bring the insurer's medical card when admitted, sparing them cash-flow concerns and the hassle of filing claims. However, the service is usually limited to network doctors and hospitals, and you must apply to the insurer in advance, a specified number of working days before admission.

5. What is the difference between making a claim through an insurance adviser and the customer filing the claim themselves?

In principle, insurance companies treat claims submitted through an adviser and those submitted by a customer equally. The main difference is that an insurance adviser with extensive claims experience can help catch omissions and follow up, preventing document errors — for example, the aforementioned issue of a claims form lacking the hospital's stamp, which can cause extra trouble for the patient and their family. A good insurance adviser can avoid this situation.

6. What should I do if an insurance company rejects my claim or the claim payout is insufficient? Where can I file a complaint?

It depends on the cause. Take "insufficient claim payout" as an example: some older or entry-level medical insurance plans use an itemized limit structure, meaning each benefit item has a separate reimbursement limit — for example ward and meal charges, or attending doctor's ward visit fees — so it’s easier to exhaust a claim, resulting in an insufficient claim payout.

As for other situations, if the client disagrees with the claim outcome, they can first negotiate with the insurance company. If still dissatisfied with the complaint outcome, they can lodge a complaint with the Insurance Complaints Bureau.

Note:

1. This article was produced by 10Life using market information gathered from various sources and is for general reference only. It does not take into account any individual needs or suitability and should not be regarded as sales advice. Before purchasing insurance, you should discuss a suitable insurance plan with a licensed insurance adviser and rely on the information provided by the insurance company.

2. Last updated: 19 April 2022.

This English version of this article has been generated by machine translation powered by AI. It is provided solely for reference purposes. In the event of any discrepancy or inconsistency between this translation and the original Chinese version, the Chinese version shall prevail.

10Life 編輯團隊

團隊成員由一群資料搜集員組成，主力保險相關資訊研究。

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10Life 編輯團隊

團隊成員由一群資料搜集員組成，主力保險相關資訊研究。

About Author

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Table of Content

【Claim Insurance】Complete Breakdown of Claims Procedures and Important Documents — 6 Must-Know Things

1. Why is it so difficult to claim medical insurance?

2. Claim period — how long will it take to receive the money?

3. List of documents required for a claim?

4. Does "discharge without settling the bill" require prior approval?

5. What is the difference between making a claim through an insurance adviser and the customer filing the claim themselves?

6. What should I do if an insurance company rejects my claim or the claim payout is insufficient? Where can I file a complaint?

Table of Content

Trending

Table of Content

【Claim Insurance】Complete Breakdown of Claims Procedures and Important Documents — 6 Must-Know Things

1. Why is it so difficult to claim medical insurance?

2. Claim period — how long will it take to receive the money?

3. List of documents required for a claim?

4. Does "discharge without settling the bill" require prior approval?

5. What is the difference between making a claim through an insurance adviser and the customer filing the claim themselves?

6. What should I do if an insurance company rejects my claim or the claim payout is insufficient? Where can I file a complaint?

Table of Content

Trending