醫療保險「全數賠償」都未必賠得足!(Chinese Article)

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20 Jun 2019
醫療保險宣傳標榜「全數賠償」?為什麼有機會Claim唔到呢?雖然「全數賠償」的醫保產品沒有為每個醫療項目設賠償上限,但賠定唔賠,要視乎索償是否符合「醫療所需」及「合理及慣常」兩大原則。消委會*最近就發表研究報告指出,不同保險公司對於「醫療所需」的定義有很大的分野。如果大家想「安心」用醫保入住私立醫院,就記得要留意啦!

「醫療所需」(Medically Necessary)要求受保人的住院及醫療服務符合一般醫療慣例,以及合乎病情診斷及治療。假如受保人純粹貪方便、舒適,而非為了治療而住院,這便不屬於「醫療所需」,保險公司可以不賠,要了解各間保險公司的定義,可參閱這一篇文章。過往曾經有爭議,究竟由保險公司、還是受保人的醫生來界定「醫療所需」?現時大家關心的自願醫保,亦為「醫療所需」定義著墨,當中多次提及住院及醫療服務需經過註冊醫生審慎的專業判斷

至於「合理及慣常」(Reasonable and Customary),意指相關住院、治療的醫療收費等必須是「合理及慣常」,不超過提供該醫療服務當地的慣常收費水平。這項條款的目的,是為了避免濫收醫療費用的潛在風險,這對於「全包」的高端醫保尤其重要。不過,何為慣常收費水平,舉例,照腸鏡值幾多錢,高端醫保內「合理及慣常」條款定義並沒有清晰定明;反而大眾醫保就有為每個手術、細項訂明賠償上限。

消委會報告有關報道的相關連結:http://bit.ly/2WOp0eX
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