Group Medical Insurance Coverage is Limited: Utilise Self-Pay Medical Insurance for Comprehensive Protection Upgrade

false

Category

Author

Search for Articles

Trending Keywords

Many employees are grateful that their companies provide group medical insurance (commonly known as company medical insurance), which allows them to consult doctors at a low cost or even for free for minor ailments like colds, and to claim expenses for stays in private hospitals. However, the coverage of company medical insurance is often insufficient. 10Life has previously surveyed multiple group medical insurance plans in the market and found that the coverage is typically determined by job level. For most junior to mid-level employees with a monthly salary of approximately HKD 35,000 or below, the coverage is particularly limited. If an employee unfortunately requires hospitalisation, they may need to bear significant out-of-pocket medical expenses. In fact, working individuals may consider first understanding their group medical insurance and then supplementing it with a medical insurance plan with a deductible (also known as a co-payment). By leveraging both, they can achieve comprehensive medical protection at a lower premium.

Basic Group Medical Insurance Limited to Standard Wards – Significant Gaps in Coverage for Serious Illnesses Cannot Be Ignored

Generally speaking, typical group medical insurance offered by large enterprises in Hong Kong provides outpatient and inpatient coverage. Outpatient coverage is subject to annual and per-visit compensation limits, as well as restrictions on the number of visits, covering both general and specialist consultations. However, specialist consultations usually require a valid referral letter. As for inpatient coverage, group medical insurance often adopts a "sub-limit structure," setting compensation caps for each coverage item (such as room charges, surgical fees, miscellaneous expenses, etc.). Additionally, basic-level group medical insurance typically restricts employees to staying in standard wards (also known as general wards), and the coverage is generally inferior to the standard plans under the Voluntary Health Insurance Scheme (VHIS). Below is an overview of the coverage for basic-level group medical insurance:

Main Coverage Items	Compensation Limit
Room and Board	Daily approx. HKD 650-800
Miscellaneous Expenses	Annually approx. HKD 10,000-15,000
Surgical Fees	Per condition approx. HKD 10,000 (minor surgery) to HKD 45,000 (complex surgery)
Outpatient	Annually approx. HKD 4,000-5,000 (subject to per-visit compensation and number of visits)

To better understand the coverage of medical insurance, 10Life consulted several specialist doctors to obtain estimated medical expenses for various common medical conditions and the associated medical services involved. Subsequently, 10Life actuaries compared these with the compensation limits listed in the benefit schedules of various medical insurance products to calculate the expected coverage ratio of the products (see Note 1). For basic-level group medical insurance targeting junior to mid-level employees, the coverage can vary significantly depending on the severity of the condition. Below are the expected coverage ratios for several medical conditions (see Note 1), including both major and minor illnesses. However, please note that the coverage limits of group medical insurance vary across companies, which will affect the actual coverage ratio. Therefore, it is important to understand the coverage limits of your own group medical insurance.

Basic-Level Group Medical Insurance (Standard Ward): Comparison of Estimated Medical Expenses, Estimated Compensation, Estimated Out-of-Pocket Expenses, and Expected Coverage Ratio

As shown in the chart above, group medical insurance provides reasonable coverage for non-severe conditions. For instance, a colonoscopy performed at a day clinic (commonly known as "colonoscopy") can achieve an expected coverage ratio of up to 100%. For minor surgeries like haemorrhoid removal, group medical insurance may cover around 90%, with the insured bearing approximately HKD 4,700 out of pocket. Based on claim data, such "minor illness" cases are quite common.

However, when the insured suffers from a "major illness," the coverage gaps in group medical insurance become evident. For coronary angioplasty (commonly known as "balloon angioplasty") with stent placement, group medical insurance is expected to cover only about 30%, leaving the insured to pay approximately HKD 150,000 out of pocket, which is a significant expense. If the insured is diagnosed with cancer and requires surgery and targeted therapy, even if the group medical insurance covers targeted drugs, these may only fall under miscellaneous expenses, with very limited actual reimbursement. As a result, the expected coverage of group medical insurance is less than 20%, and the insured may need to pay nearly HKD 400,000 out of pocket. For severe kidney disease patients requiring haemodialysis (also known as "blood dialysis"), the coverage provided by typical group medical insurance is negligible, and the insured may need to bear costs exceeding HKD 300,000.

Self-Purchased Medical Insurance with Deductible – Enhancing Coverage at a Lower Cost

Since group medical insurance does not provide comprehensive medical protection, many consumers take proactive steps by purchasing individual medical insurance to address these coverage gaps. For clients with group medical insurance, insurance advisors often recommend Top-up plans with deductibles or high-end medical insurance plans. The deductible and premium are inversely related: the higher the deductible, the lower the premium.

Since the introduction of the Voluntary Health Insurance Scheme (VHIS) by the government, many consumers have deliberately chosen VHIS-certified medical insurance products due to their clear and standardised terms, as well as the tax deduction benefits available to policyholders. However, VHIS products with deductibles in the market typically cover private or semi-private wards. As for the more affordable standard wards, as of the publication date (15 May 2020), among VHIS plans that designate standard wards as the ward level, only AXA Hong Kong and Macau Smart Elite Medical Protection (Standard) offers a deductible option.

In practice, consumers can determine the coverage limits of their group medical insurance and their financial capacity, then decide on a self-purchased medical insurance plan with an appropriate deductible to lower the premium. As mentioned earlier, the coverage ratio of basic-level group medical insurance is quite limited. By adding a standard ward plan with a deductible, the coverage can be significantly enhanced, using AXA Hong Kong and Macau Smart Elite Medical Protection (Standard) as an example.

Group Medical Insurance + VHIS: Significantly Reducing Consumers' Estimated Medical Expenses

The data in the chart above shows that, assuming the compensation from group medical insurance is used to offset the deductible, pairing it with AXA Hong Kong and Macau Smart Elite Medical Protection (Standard) with a deductible of HKD 20,000 or HKD 50,000 significantly enhances the insured’s coverage for procedures like balloon angioplasty and severe cancer requiring targeted therapy. Through these two insurance plans, full compensation can potentially be achieved. As for haemodialysis, the insured’s expected out-of-pocket medical expenses are significantly reduced from the original HKD 320,000 (under group medical insurance alone) to HKD 16,000 to 46,000 (see Note 1).

When considering using group medical insurance alongside medical insurance with a deductible to achieve better medical protection, please take note of the following points:

Medical insurance claims are subject to time limits, typically within 30 days after treatment or discharge. The insured must submit the claim application form and other supporting documents. Since you may need to file claims with different insurance companies twice, ensure you allocate sufficient time. To avoid delays in claims, the insured can gather several claim forms and have the attending doctor complete them all at once, then submit them along with hospital receipts and relevant pathology reports to the insurance companies. During the first claim, remember to request certified copies of the documents from the insurance company to facilitate a quicker claim with the second insurer. You may also inform your insurance advisor (if any) before hospitalisation to assist with follow-up.

Group medical insurance is only available to employees. If you resign, change jobs, or retire in the future, you may lose your group medical insurance. At that point, you might wish to lower the deductible of your medical insurance. Some medical insurance plans allow the insured to adjust the deductible option without requiring re-underwriting, avoiding potential impacts on coverage due to changes in health conditions that may require re-underwriting. It is important to clarify these details when purchasing the policy.

This article only discusses a limited number of VHIS standard ward plans to illustrate the application of combining group medical insurance with self-purchased medical insurance. For more information on VHIS products, you can visit the 10Life website’s 《Product Decoder》 for in-depth comparisons.

Note:

The expected coverage ratio for the above medical conditions is calculated based on the estimated medical expenses under general circumstances for those conditions. It is used to estimate the expected compensation amount of medical insurance and the consumer’s expected out-of-pocket expenses, and is for reference only. Users should not consider it as actual medical expenses. The severity of each medical condition, the required treatment, and the insurance company’s claim assessment may differ, all of which can affect the actual compensation amount for the insured. For details, refer to 《10Life’s Rating Methodology for Public Medical Insurance》.

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.

Last updated: 9 Apr 2026

10Life Editorial Team

Our team of professional content researchers focussing on insurance

About Author

10Life Editorial Team

Our team of professional content researchers focussing on insurance

About Author

Disclaimer

10Life Product Comparison and 10Life Insurance Ratings are developed by 10Life Financial Limited, an authorised insurance broker company licensed with the Insurance Authority under License Number FB1526. 10Life Product Comparison and 10Life Insurance Ratings are developed for generic customer segments using mathematical calculations based on product information, facts and data, and are not influenced by any partnerships with or fees received from insurance companies. Any information on 10Life Platform ("10Life Information"), including but not limited to Product Comparison, Product Ratings, Blog Articles are intended for general education purpose and reference only. None of the 10Life Information is intended, nor should they be considered or relied upon, as regulated advice, insurance, financial, investment or professional advice, recommendation, approval, endorsement, invitation or solicitation in respect of any insurance, financial or investment products. 10Life Information does not take into account your individual needs. Reading 10Life Information should not be considered as conducting a suitability assessment, and is not sufficient to form the basis of any decisions to purchase any insurance products. You should rely on information authorised by insurance companies, carry out your own research and/or seek independent advice from licensed intermediaries before purchasing any insurance products or making any insurance decisions. While reasonable effort is used when collecting, validating and updating 10Life Information from various channels, none of 10Life Group and its subsidiaries, affiliates, agents, directors, officers and employees will be responsible for any liability, claim or loss arising from or associated with you using 10Life Information. No warranty, representation or guarantee is given by 10Life Group and its subsidiaries on the accuracy, completeness and timeliness of the information. If you have any questions on 10Life Product Comparison and 10Life Insurance Ratings, please email us at enquiries@10life.com

Trending

Group medical insurance has limited coverage. Make good use of self-paid medical insurance for comprehensive protection upgrades.

Trending