[Insurance Clinic] Minimally conscious state mistaken as a vegetative state. Is the insurer trying to cut corners?

Background:

Mr Lau is an insurance practitioner himself. Many years ago, he bought a high-end medical insurance policy from his own company, with a lifetime benefit limit of up to HK$60 million. Unfortunately, he suffered a brain haemorrhage and was admitted to hospital. In 2020, he received emergency treatment at a public hospital and was later transferred to a private hospital. Claims under the high-end medical insurance policy were processed smoothly until December 2021, but claims submitted after mid-December 2021 were delayed, and the insurer was unable to provide a clear response.

Eventually, in mid-June 2022, after Mrs Lau lodged a complaint with the regulator, she officially received a written notice from the insurer declining the claim. The stated reason was that the insured had remained in a vegetative state for more than 28 consecutive days, with consciousness but no awareness, and had received treatment in hospital for more than 90 consecutive days.

However, the medical certificate issued by Mr Lau’s attending doctor stated that Mr Lau was in a minimally conscious state, rather than the persistent vegetative state mentioned by the insurer. Mrs Lau also said that Mr Lau was able to wear glasses, throw a ball and recognise people, and that the insurer had concluded he was in a vegetative state without visiting the patient.

At present, the dispute between Mrs Lau and the insurer involves more than HK$1 million. Mr Lau is receiving treatment in a convalescent hospital, and the family is still arguing their case with the insurer. However, neither the insurer’s claims department nor customer service department has been able to provide appropriate assistance.

Case analysis:

We were interviewed by TVB’s Dolce Vita about this matter and considered that cases of this type are not common. The insurer relied on the vegetative state exclusion clause, the definition of which is “conscious but without awareness”. However, the attending doctor stated clearly that the claimant was in a minimally conscious state. Medically, the two conditions are clearly different, so the insurer’s refusal to pay is unreasonable.

If the insurer disagrees with the attending doctor’s opinion, it can appoint an independent doctor to review the claimant’s medical report and decide whether to make a claim payment. If the insurer has not taken this step, we believe Mrs Lau should continue to press the matter and file complaints with the Insurance Authority and the Insurance Complaints Bureau.

We would also like to remind all policyholders that vegetative state or similar conditions being listed as exclusions in medical insurance policies is not uncommon. Some high-end medical insurance policies commonly include a vegetative state exclusion clause, while some medical insurance products, such as Voluntary Health Insurance, do not have such clauses. This may be because the former has a higher annual benefit limit. Policyholders should compare the policy terms carefully.

In addition, the claimant himself is an insurance agent. He originally intended to purchase medical insurance and make a claim for himself, but the current situation is exceptionally difficult. His supervisor, as an insurance agent, should step in to help. However, the difficulty is that they themselves represent the insurer, so even if they intend to pursue the matter through legal means, they would find it difficult to sue their own company on behalf of the policyholder. By contrast, insurance brokers represent clients and therefore have grounds to complain to insurers.

Finally, if readers have any questions or concerns about policy claims, please feel free to contact 10Life Financial. Our claims specialists focus on helping customers secure fair compensation, guiding them to submit the required documents to the insurer, following up on claim progress in a timely manner, and reviewing whether the insurer’s compensation amount is sufficient. If the insurer refuses to pay or offers insufficient compensation, our claims specialists will represent the customer in seeking a better outcome.

Email: enquiries@10life.com

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.