Unfinished Controversy on Hang Seng Covid Benefit

Estimated reading time 4 minutes

10Life Team

23 May 2022
恒生18萬保障爭議未完  索償時間太長?
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10Life Team

23 May 2022

Estimated reading time 4 minutes

恒生保險今年初推出一項「新冠肺炎確診附加保障」(簡稱「恒生18萬保障」),近月曾經一度鬧出「拒保」或「拒賠」風波

近月再有受保人控訴,指他們滿足有關保險產品之索償條件後,恒生再致函要求有關醫療機構補交更多受保人相關資料,並稱文件補交時間可長達由確診日起計180日,究竟恒生索償時間是否太長?索取資料是否太多?

1. 正常而言,保險理賠時間通常幾長?


若果受保人向保險公司展開索償,保險公司理賠程序隨即展開,理賠時間長短視乎產品複雜程度、索償金額、以及保險公司行政程序。

一般而言,簡單網上產品可以即時理賠,但一些產品例如醫療保險則較複雜,尤其是如果涉及早期索償(Early claim),理賠時間可能長達數個月甚至是 1年以上,視乎醫療報告處理進度及保險公司行政程序等種種因素。

不過,「恒生18萬保障」這項附加保障本身並不複雜,而且受保人賠償金額一致,只需要在保障期內提供核酸(PCR)檢測結果,以及註冊醫生證明受保人確診,保險公司就要作出賠償。

2. 「恒生18萬保障」索償時間是否太長?


據了解,恒生致客戶的信件中,提及就有關索償個案要找醫療機構提供醫事報告,亦指出因應疫情醫生或醫療機構可能需要更長時間提供文件及證明,故此補交文件日期最長為確診日起計180日。

正如上述所言,「恒生18萬保障」產品結構並不算複雜,除非個案本身有一些特殊因素,或醫療機構在文件處理上出現困難,或保險公司索償個案積壓及行政時間過長,否則索償時間應該不會長達180日。

3.保險公司一開始已經訂立索償準則,其後需要更多證明是否正常?


首先,從保險公司角度,索償表格的免責條款其實亦有列明保險公司保留權利去問受保人更多資料或紀錄。

而保險公司向受保人索取資料,通常牽涉兩項原則——以「恒生18萬保障」為例,保險公司或希望確認受保人確診新冠肺炎病歷,或受保人是否觸發一些不保事項,例如等候期內確診,或有證據顯示蓄意確診。

據恒生保險致醫療機構之信函,恒生提供部份問題確實有理據去發問,例如受保人確診前有沒有進行過快速測試、核酸測試進行方法等。

例子:

Is there any Rapid Antigen Test done for the patient before first consultation?

Was the specimen collection of PCR test performed in person by your clinic?

但部份問題與「恒生18萬保障」未必有太大關係,例如醫療機構過往為病人提供的診症及手術等歷史、是否定時定候去醫院或診所進行檢查或檢驗,這些問題答案並不影響受保人是否確診新冠肺炎的事實。

例子:

Please list details of all medical conditions that your patient has consulted you.

Did the patient have any routine check up in your hospital/clinic? If so, please provide details.

唯一是上述問題可能涉及受保人本身在購買保險時是否出現「漏報」情況,導致本身購買的保險產品反而被拒保。

4.若果認為理賠時間太長,受保人有甚麼辦法申訴?


我們認為受保人現時可以耐心等待,原因是現階段保險公司尚未明確拒絕賠償。我們相信若果受保人完全符合索償條件,保險公司最終亦不能拒保。

不過,如果保險公司真的拒保,而有關原因受保人認為並不合理,我們建議應向有關保險公司作出投訴;若果未能解決爭議,則可考慮申訴至保險投訴局,最後就是採取法律行動。

我們認為,就索償機制及所涉及的程序和時間,保險公司應該要提升透明度,並與公眾及客戶多作溝通,減少出現誤解。

註:本文最後更新日期:2022年5月24日

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