[Insurance Clinic] Does an accidental fracture count as a knee condition? Wrong advice from an agent nearly cost a claim.

Mr Chan (pseudonym) has in recent years purchased a high-end medical insurance policy for his father through an insurance broker. He disclosed to the insurer that his father had undergone knee surgery many years ago and had previously suffered from arthritis in his shoulder. As a result, the policy’s exclusion clause specified that “knee conditions” and “arthritis” were not covered.

Mr Chan asked the insurance broker whether the “arthritis” exclusion applied only to the shoulder that had previously been affected by arthritis, or to all joints throughout the body. The broker stated that the “arthritis” exclusion applied only to the shoulder, and Mr Chan therefore signed the relevant exclusion clause.

Later, after slipping on a wet and slippery surface during rainy weather, Mr Chan’s father accidentally fractured his left knee and underwent an operation at a private hospital, costing nearly tens of thousands of Hong Kong dollars. As the high-end medical insurance policy stated “no item limits, full reimbursement”, Mr Chan, through the insurance broker, claimed the medical expenses from the insurer.

Unfortunately, the insurer refused to make any payment, on the basis that the knee fracture caused by Mr Chan’s father’s accident fell within the scope of “knee conditions”. Mr Chan was dissatisfied, believing that an “accidental fracture” is not the same as a “knee condition”. What was even more serious was that he discovered the definition of the “arthritis” exclusion actually covered all joints throughout the body.

After hearing this reader’s story, the author suggests that Mr Chan should seek the opinion of a specialist doctor, including obtaining a doctor’s confirmation that a fracture caused by an accident is not the same as a disease. The relevant specialist doctor also helped by providing a signed letter stating that Mr Chan’s father’s kneecap fracture was not a “knee disease”.

In the end, the insurance company exercised its discretion to provide full reimbursement of one-off surgery and related expenses for that accident. However, Mr Chan remained dissatisfied with the outcome and requested that, even if his father were to suffer any future accident resulting in a kneecap fracture, the insurer must not refuse a claim on the grounds of “knee disease”.

As for the “arthritis” issue, the author suggests that Mr Chan may consider making a complaint to the Insurance Authority, as the broker had clearly misinterpreted the exclusion clause, misleading Mr Chan into believing that “arthritis” only excluded the shoulders rather than all joints, which amounts to professional misconduct.

However, as Mr Chan did not have any audio recording or screenshots of the conversation when the broker gave him the incorrect advice, this is expected to become a major obstacle to the complaint. Therefore, when policyholders consult insurance intermediaries on key issues, it is advisable to keep audio recordings or documentary evidence.

Finally, if readers have any questions or issues regarding policy claims, they are welcome to contact 10Life Financial. 10Life Financial’s claims specialists focus on securing fair compensation for clients, and guide them in submitting the required documents to insurers, follow up on the claims progress in a timely manner, and review whether the insurer’s compensation amount is sufficient. If the insurer refuses the claim or offers insufficient compensation, the claims specialists will negotiate with the insurer on the client’s behalf.

Email: enquiries@10life.com

Note: 10Life Financial’s claims specialists are licensed insurance intermediaries authorised by the Hong Kong Insurance Authority.

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.