10Life Financial Limited
Enquiries: enquiries@10life.com
Hotline: (852) 3705 1599
Address: 16/F Greatmany Centre, 109-115 Queen’s Road East, Wan Chai, Hong Kong
Talk to 10Life on WeChat
false
Trending
Trending
Table of Content
1. Why is medical insurance so difficult to Claim?
2. How long does it take to make a claim and receive the payment?
3. List of claims documents?
4. Does “Discharge without Payment” require pre-authorisation?
5. What is the difference between making a claim yourself and making one through an insurance adviser?
6. What should I do if the insurance company rejects my Claim or the Claim payout is insufficient? Where can I lodge a complaint?
Category
Author
Search 
Category
Author
Search
【Claim Insurance】Claims procedures and essential documents explained: 6 things you must know.
Insurance is often criticised for being easy to buy but difficult to Claim on, with medical insurance in particular giving rise to many disputes. In many cases, policyholders are unable to Claim the full amount, or are unable to Claim at all. In reality, is it really so difficult to make a Claim from an insurance company? Today, using medical insurance as an example, we explore six key matters, including the Claim process and required documents.
1. Why is medical insurance so difficult to Claim?
The first common reason is that, when applying for insurance, customers fail to proactively disclose “material facts”, such as omitting details of their medical history, resulting in the policy being invalidated or a claim being rejected. It is worth noting that if a customer applies for insurance through an insurance adviser, the adviser is also responsible for reminding the customer to disclose material facts, as well as the serious consequences that may result from failing to do so.
The second reason is that the medical expenses in question involve excluded items, such as medical services arising from taking an excessive dose of medication, deliberately injuring oneself, participating in illegal activities or having a sexually transmitted disease. In addition, some older medical insurance plans do not cover day hospitals or day surgery.
Moreover, medical insurance only reimburses medical expenses incurred for reasons that are medically necessary, but the insurance company determines whether a particular treatment is medically necessary. For example, not every insurance company explicitly considers breast reconstruction surgery following a mastectomy to be medically necessary.
Therefore, before being admitted to hospital, customers should first check with their insurance adviser whether the treatment is covered. Some products also offer pre-admission assessment services, which can assess quotations for treatments provided by doctors and help avoid disputes.
2. How long does it take to make a claim and receive the payment?
The deadline for submitting a medical insurance claim is usually 30 to 90 days after discharge or surgery, depending on the insurance company’s policy.
Upon receiving the documents, the insurance company will review and assess the claim. Insurance companies are generally stricter when handling claims made within the first two to three years after taking out a policy (i.e. early claims), and may contact the Hospital Authority or relevant medical institutions to obtain the patient’s medical records. As a result, the claim may take at least 8 to 12 weeks to process. For claims that are not early claims, processing usually takes around 4 weeks.
3. List of claims documents?
To claim hospital medical expenses, the policyholder must submit the claim form and supporting documents within the specified period, which generally include:
1. Claim form (some sections must be completed by the attending doctor and bear the hospital stamp).
2. Original medical receipts and invoices.
3. Laboratory, ultrasound, X-ray, computed tomography, magnetic resonance imaging and pathology reports.
4. Referral letter from the doctor or hospital.
5. Copies of the Hong Kong Identity Cards of the policyholder and the insured.
If the policyholder intends to make a claim with more than one insurance company, they must prepare the claim form of the other insurance company. Similarly, some sections must be completed by the attending doctor and bear the hospital stamp.
In addition, when making a claim with the first insurance company, they must request the return of the original medical receipts or verified copies thereof, as well as a copy of the first insurance company’s benefit statement, in order to submit a claim form to the other insurance company.
4. Does “Discharge without Payment” require pre-authorisation?
Many medical insurance plans promote a “cashless discharge” service, allowing policyholders to bring only their insurer’s medical card when admitted to hospital, thereby avoiding cash-flow concerns and the hassle of handling claims. However, this service is generally limited to network doctors and hospitals, and an application must be submitted to the insurer in advance, usually a specified number of working days beforehand.
5. What is the difference between making a claim yourself and making one through an insurance adviser?
In principle, insurance companies treat claims submitted through consultants and those submitted directly by clients equally. The main difference is that an insurance consultant with extensive claims experience can help identify omissions and follow up, avoiding errors such as missing documents. For example, as mentioned above, a missing hospital stamp on a claim form may cause inconvenience to the patient and their family, whereas a good insurance consultant can help avoid this situation.
6. What should I do if the insurance company rejects my Claim or the Claim payout is insufficient? Where can I lodge a complaint?
This depends on the reason. Taking “Claim唔足” as an example, some relatively old or entry-level medical insurance policies adopt a structure with sub-limits, whereby each benefit item has a separate claim limit, such as room and board and attending physician ward round fees. As a result, it is easier to Claim爆, leading to Claim唔足.
As for other situations, such as when a customer disagrees with the claim outcome, they may first negotiate with the insurance company. If they remain dissatisfied with the outcome of the complaint, they may lodge a complaint with the Insurance Complaints Bureau.
Notes:
1. This article was prepared by 10Life based on market information collected from various sources. It is provided for general reference only and does not take into account any individual needs or suitability. It should not be regarded as sales advice. Before taking out a policy, you should discuss an insurance plan suitable for you with a licensed insurance adviser, and refer to the information provided by the insurance company.
2. Last updated: 19 April 2022.
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.
10Life Editorial Team
Our team of professional content researchers focussing on insurance
10Life Editorial Team
Our team of professional content researchers focussing on insurance
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
