How to Claim Medical Insurance

Estimated reading time 4 minutes

10Life Team

26 Apr 2022
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10Life Team

26 Apr 2022

Estimated reading time 4 minutes

保險很多時候被人批評買就容易,Claim錢時就困難,當中醫療保險爭拗特別多,很多時候Claim唔足甚至Claim唔到。事實上,向保險公司索償是否真的如此困難?今天就以醫療保險為例,探討索償流程、所需文件等6大事項。

1. 點解醫療保險好難Claim?

第一個常見理由是投保時,客戶未有主動披露「重要事實」(material facts),例如漏報過往病歷,因而令保單失效或索償被拒。值得一提,若客戶經保險顧問投保,該顧問亦有責任提醒客戶披露重要事實,以及不披露可能造成的嚴重後果。

第二是相關醫療費用涉及不保事項,例如因服用過量藥物、故意自殘身體、參與非法活動、性病而產生的醫療服務費用。此外,一些較舊款的醫保計劃或不保障日間醫院或門診手術。

另外,醫療保險只賠償因醫療需要(medically necessary)而所產生的醫療費用,但該項目是否屬醫療需要由保險公司決定 。例如乳房切除後重建手術,也並非每間保險公司都直接表示屬醫療需要。

所以入院前,客戶宜先向保險顧問查詢該項目是否屬承保範圍之內,部分產品更設有入院前評估服務,可評估由醫生提供的療程報價,以避免爭議。

2. 索償期限、等幾耐收到錢?

醫療保險索償限期,通常為出院或手術後30日至90日,視乎保險公司政策。

收到文件後,保險公司將進行審查和批核。保險公司一般對於投保後兩至三年內的索償(即早期索償)較為嚴格,或會向醫管局或相關醫療機構查詢病人病歷資料,因此賠償時間最少需要8至12個星期。至於非早期索償,則大概於4星期內。

3. 索償文件清單?

如欲索償住院醫療開支,保單持有人須於該指定日期內提交索償表格及證明文件,一般包括:

1. 索償表格(部分須由主診醫生填寫,並附有醫院蓋章)。
2. 醫療收據及收費單正本。
3. 化驗室、超聲波、X光、電腦掃描、磁力共振及病理報告。
4. 醫生或醫院轉介信
5. 保單持有人及受保人的香港身份證副本。

如果保單持有人打算向多於一間保險公司索償,他須準備另一家保險公司的索償表格,同樣部分須要由主診醫生填寫,並附有醫院蓋章。

此外,在向第一間保險公司索償時,須向該保險公司要求取回醫療收據正本或其核實副本,以及第一間保險公司的賠償明細表副本,以便向另一家保險公司申請索償表格。

4. 「出院免找數」須預先批核?

不少醫療保險均標榜提供「出院免找數」服務,讓入院時只需帶備保險公司醫療卡,免卻客戶現金流和辦理索償手續煩惱。不過,該服務多數只限於網絡醫生及醫院,而且須預先指定工作天之前,向保險公司預先申請。

5. 經保險顧問與客戶自行索償有何分別?

原則上,保險公司對經顧問或客戶的索償一視同仁。兩者的主要分別在於,有一位索償經驗豐富的保險顧問可以幫手執漏和跟進,避免一些文件錯漏,例如上文提到的索償表格欠缺醫院蓋印問題,有機會引致病人及其家屬的勞累,好的保險顧問則可以避免這個情況。

6. 保險公司拒賠或Claim唔足點算?可以去邊投訴?

這要視乎原因。以「Claim唔足」為例,部分比較舊或入門級的醫療保險,採取細項設限的結構,即每個保障項目設有獨立賠償上限,例如病房及膳食、主診醫生巡房費,因而較容易Claim爆,引致Claim唔足。

至於其他情況,如客戶不同意賠償結果,可先向保險公司交涉。若對投訴結果仍不滿意,可向保險投訴局投訴。

註﹕
1. 本文由10Life從不同途徑搜集市場資料製作而成,僅供一般參考之用,並沒有考慮任何個人需要及合適性,亦不應被視為銷售建議。投保前應與持牌保險顧問商討適合自己的保險方案,並以保險公司提供的資料為準。
2. 本文最後更新日期:2022年4月19日。

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