VHIS Standard Plans are far from standard: coverage for post-mastectomy breast reconstruction varies, with insurers each setting their own ‘goalposts’.

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A young woman who purchased a Voluntary Health Insurance Scheme (VHIS) plan early on was unfortunately diagnosed with Stage III breast cancer. After undergoing a mastectomy, she immediately underwent breast reconstruction surgery. However, when she subsequently submitted a claim to the relevant insurer, the insurer was only willing to reimburse the mastectomy costs and rejected the claim for the reconstruction surgery.

When women develop breast cancer, they are highly likely to require a mastectomy to remove the cancerous cells directly. Many younger patients undergo breast reconstruction immediately after the mastectomy to restore the appearance of the breast.

Academic journals have noted that reconstruction surgery following a mastectomy can help enhance women’s quality of life, dignity and physical appearance. In fact, breast reconstruction is often regarded as part of the overall treatment process for breast cancer.

Table 1: Details of breast reconstruction coverage under healthcare plans in different countries and regions

Country or region	Healthcare plan	Details of breast reconstruction coverage
United States	WHCRA group insurance	Provides that where group insurance covers mastectomy, it must also cover breast reconstruction surgery
	Medicare	Covers reconstruction surgery resulting from a mastectomy
	Medicaid	Depends on the state; for example, it is covered in Washington State
United Kingdom	National Health Service	Covers the repair or reconstruction of body tissue lost or damaged due to illness or an accident, including the breasts
Hong Kong	Public hospitals	The relevant surgery costs are included in the hospital fees, and patients do not need to pay any additional charges
Hong Kong	Voluntary Health Insurance Scheme	Standards vary

US and UK health insurance cover reconstruction after mastectomy

There is no international doubt that medical insurance should cover mastectomy triggered by breast cancer. However, Hong Kong falls behind international standards as to whether it should cover breast reconstruction surgery performed immediately afterwards. It is worth noting that, unlike general cosmetic surgery, breast reconstruction is a restorative procedure following illness or injury.

In the United States, for example, the Women’s Health and Cancer Rights Act (WHCRA) was enacted as federal law in 1998. It provides that where group insurance covers mastectomy, it must also cover breast reconstruction surgery, benefiting at least several thousand women. Insurers may also be sanctioned if they refuse to pay for reconstruction in any way or induce patients not to undergo breast reconstruction.

As for the US national health insurance programmes Medicare and Medicaid, although they are not covered by the WHCRA, the former naturally covers reconstruction surgery resulting from a mastectomy, while the latter depends on the state. For example, it is covered in Washington State.

Let us also look at the UK National Health Service (NHS). Those insured under the NHS would of course have to pay for ordinary cosmetic surgery themselves. However, the repair or reconstruction of body tissue lost or damaged due to illness or an accident is covered, including claims for breast reconstruction surgery after a mastectomy resulting from breast cancer.

Hong Kong public hospitals waive fees for reconstruction after mastectomy

Having considered the coverage criteria for reconstruction after mastectomy under the national health services of the United States and the United Kingdom, let us return to Hong Kong. Hong Kong does not have a universal health insurance scheme, but public healthcare is often inexpensive or even free. A breast cancer patient receiving a mastectomy in a public hospital does not need to pay an additional surgical fee. Would the cost of breast reconstruction surgery also be covered?

10Life asked the Hospital Authority about this issue. A Hospital Authority spokesperson said that plastic surgeons and breast surgeons assess the need for and suitability of breast reconstruction surgery, but stated that it is not an essential operation for cancer treatment.

Nevertheless, the spokesperson said that for patients receiving public healthcare services, the relevant surgery costs are included in the hospital fees and patients do not need to pay any additional charges. The current hospital fee for eligible persons at hospitals under the Hospital Authority is HK$100 per day.

The VHIS “Standard Plan” is not standard

Patients undergoing breast reconstruction in public hospitals do not need to pay a surgical fee. Would the VHIS Standard Plan, which aims to relieve pressure on public healthcare and whose “rules” are determined by the Food and Health Bureau, cover the cost of a young woman undergoing reconstruction after a mastectomy for breast cancer?

10Life asked the VHIS Office under the Food and Health Bureau. The bureau replied that whether breast reconstruction surgery constitutes “medically necessary” treatment must be determined according to the circumstances of each individual case, including whether the surgery satisfies various conditions (see below), such as being required for the diagnosis and treatment of the illness or injury and being provided in accordance with the attending registered doctor’s prudent professional judgement. It is therefore difficult to reach a general conclusion.

Principles of “medical necessity” mentioned by the Food and Health Bureau

(a) The professional knowledge of, or referral by, a registered doctor is required;

(b) It is required for the diagnosis and treatment of the illness or injury;

(c) It is provided in accordance with good and prudent medical standards and the attending registered doctor’s prudent professional judgement, rather than primarily for the convenience or comfort of the insured person, their family members, carers or the attending registered doctor;

(d) The medical service is provided in the most appropriate setting and with equipment that meets generally accepted medical standards;

(e) It is provided safely and effectively to the insured person at the most appropriate level, as determined by the attending registered doctor’s prudent professional judgement.

After receiving the Food and Health Bureau’s “standard answer”, we used the contact list on the Insurance Authority’s website to ask more than 20 insurers individually whether their VHIS Standard Plans would cover breast reconstruction surgery resulting from breast cancer. Only around 30% confirmed that they would provide such coverage.

Our questions were: “If a young woman with breast cancer needs to undergo a complete mastectomy followed by breast reconstruction surgery, would the latter reconstruction surgery constitute a medical necessity?” and “If the product does not expressly specify coverage for breast reconstruction surgery, such as under the VHIS Standard Plan, would breast reconstruction surgery nevertheless be covered?”

Will VHIS pay? The insurers’ responses were...

We received three main types of response. First, Asia Insurance, AXA, Bowtie, Bupa, Cigna, FWD, YF Life and Prudential all stated that their VHIS Standard Plans would reimburse breast reconstruction surgery triggered by a mastectomy for breast cancer.

Some insurers did not directly respond as to whether they would provide coverage in the scenario described above. For example, Manulife and Sun Life merely reiterated that their VHIS plans would provide coverage subject to conditions including medical necessity. Some insurers also said that their more expensive VHIS “Flexi Plans” would cover the cost of reconstruction surgery after a mastectomy.

Although AIA told 10Life that claims would be determined according to the attending doctor’s professional assessment of the patient’s best interests and medical needs, based on the principle of “reasonable customer service” and with reference to the contractual provisions, terms and exclusions of the relevant policy, as well as the facts and circumstances of each claim, we received a complaint from a reader that AIA’s VHIS plan classified reconstruction surgery immediately following a mastectomy as an excluded item (see Figure 1).

Figure 1: The claim document provided by the patient states that reconstruction surgery after mastectomy is excluded (General Exclusion)

Table 2: Do VHIS Standard Plans cover breast reconstruction surgery triggered by a mastectomy for breast cancer?

VHIS provider	Covered?	Response
AIA	✗	Said that this would depend on the customer’s best interests and medical needs, but a real case showed that the claim was rejected
Asia Insurance	✓	Reimbursement is provided according to the policy benefit schedule
AXA	✓	It constitutes a medical necessity
Bowtie	✓	Covered, including breast reconstruction surgery triggered by an unusual accident
Bupa	✓	It constitutes a medical necessity
Cigna	✓	It constitutes a medical necessity
FWD	✓	Coverage will be provided
HSBC Life	✓	It constitutes a medical necessity and will be covered
Prudential	✓	It constitutes a medical necessity
YF Life	✓	It constitutes a medical necessity
Blue Cross	？	Vague response; only stated that the “Flexi Plan” would provide coverage
Manulife	？	Vague response; said that it would depend on the actual circumstances, medical necessity and other factors
Sun Life	？	Vague response; said that the definition of medical necessity must be satisfied
ZA Life	？	Vague response; said that the policy definition and medical records must be satisfied
Allianz Life	No response
Avo	No response
BOC Life	No response
China Life Overseas	No response
China Taiping	No response
Chubb Life	No response
Dah Sing Insurance	No response
Ftlife Insurance	No response
Hong Kong Life	No response
Liberty Insurance International	No response
Mitsui Sumitomo	No response
Well Link Life	No response
Zurich Insurance	No response
Notes: 1. The question put to insurers was: “If a young woman with breast cancer needs to undergo a complete mastectomy followed by breast reconstruction surgery, would the latter reconstruction surgery constitute a medical necessity, and would the relevant VHIS plan provide coverage?” 2. “Vague” means that the response merely reiterated that the case must be medically necessary or did not directly answer the question. 3. The enquiries were sent using the contact details of insurers listed on the Insurance Authority’s website. 4. The findings for AIA were based on a genuine patient case. 5. The above information was accurate as at 31 March 2022.

Hoping that the Food and Health Bureau will standardise the criteria

Nearly three years have passed since the launch of VHIS, which has become a safety net for many middle-class families. However, when claims arise, it turns out that insurers have different “goalposts”, and inconsistent standards may be unfair to consumers. More seriously, even the higher-priced Flexi Plans have no consistent standard for covering reconstruction surgery after mastectomy.

10Life previously exposed a loophole in the definition of “prescribed non-surgical cancer treatments” under VHIS that could lead to claim rejections. The Food and Health Bureau eventually made a definitive decision, clearly stating that such treatments would be covered provided that they were prescribed by a registered doctor on medical grounds, benefiting many patients.

According to the Hong Kong Breast Cancer Foundation, the number of breast cancer cases diagnosed among women in Hong Kong tripled between 1993 and 2019, rising from 1,152 cases in 1993 to 4,761 in 2019. On average, 13 women are diagnosed each day. We hope that the Food and Health Bureau will standardise the scope of VHIS coverage, regard reconstruction surgery after a mastectomy caused by breast cancer as medically necessary and provide reimbursement, thereby protecting the rights and interests of female patients.

Finally, if policyholders believe that an insurer has handled their claim unfairly or unjustly, they are welcome to contact 10Life on WhatsApp at 37051599. We are committed to speaking up for consumers.

Notes:

1. This article was prepared by 10Life using market information collected through various channels and is provided for general reference only. It does not take into account any individual needs or suitability and should not be regarded as sales advice. Before purchasing insurance, you should discuss suitable insurance solutions with a licensed insurance adviser and rely on the information provided by the insurer.

2. Last updated: 31 March 2022

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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

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10Life Editorial Team

Our team of professional content researchers focussing on insurance

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Voluntary Health Insurance Standard Plans aren’t standard: insurers set their own ‘goalposts’ for post-mastectomy breast reconstruction cover.

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