Does the Voluntary Health Insurance Scheme cover general outpatient care? What types of outpatient care are covered under VHIS?

Many Hong Kong people, when taking out Voluntary Health Insurance Scheme (VHIS) cover, often have one question: if they see a doctor at a clinic for an ordinary cold, fever or stomach ache, is it covered? This time, 10Life will take an in-depth look at the outpatient benefits under VHIS, from the pre- and post-hospitalisation outpatient limits under the Standard Plan to how the Flexi Plan can be extended to cover accident-related emergency treatment and rehabilitation therapy, helping everyone plan a suitable protection package wisely. 

• Voluntary Health Insurance is a hospital medical insurance scheme and generally does not cover routine general outpatient consultations for common conditions such as colds, flu or stomach ache.
• The Standard Plan only covers specified outpatient consultations related to hospitalisation or day case procedures, and is subject to strict limits on the number of visits and benefit caps.
• Advanced tests performed on an outpatient basis, such as CT and MRI scans, are covered, but a doctor’s referral is required; under the Standard Plan, the insured person must pay 30% coinsurance.
• Flexible or premium plans may additionally provide extended outpatient benefits, such as accident and emergency care, outpatient dialysis and post-operative physiotherapy.
• Only premiums within the recognised product structure are tax-deductible; separately bundled standalone outpatient riders usually do not qualify for tax relief. 

The Voluntary Health Insurance Scheme is positioned in the market as “inpatient medical insurance”. Its core protection is usually premised on “requiring hospitalisation or surgery”. In other words, coverage mainly focuses on hospital-related medical expenses rather than everyday outpatient care.

Therefore, common general outpatient consultations, such as seeing a private clinic for a cold, bronchitis or mild stomach discomfort, are generally not within the standard coverage scope of VHIS.

Before taking out a policy, you should first have clear expectations. The protection design of VHIS primarily centres on hospitalisation and surgical treatment, while outpatient-related benefits are usually limited to medical procedures directly related to hospitalisation or surgery. As for general outpatient expenses outside hospitalisation, these would need to be supplemented through outpatient insurance or other medical plans. 

Common exclusions

• General outpatient consultations: routine consultations that are neither hospitalisation nor surgery-related are generally at your own expense.  
• Preventive check-ups: outpatient examinations carried out purely for health screening or preventive purposes are usually not covered (unless the plan includes relevant services).  
• Medication for chronic conditions at outpatient clinics: if medication is not prescribed during a hospitalisation period, long-term outpatient medication expenses are generally not reimbursable. 

Although the Voluntary Health Insurance Scheme does not cover general outpatient services, under the principle of “continuity” in coverage, the Standard Plan provides pre- and post-hospitalisation outpatient benefits related to hospitalisation or day surgery, to support the whole treatment process.

This type of outpatient cover mainly includes diagnostic assessment for the same illness or injury before admission, as well as follow-up consultations after discharge. However, the relevant benefits are subject to clear limits on the number of visits and the amount payable.

• Before hospitalisation / day surgery: up to 1 outpatient consultation or A&E consultation is covered.
• After discharge / day surgery: up to 3 follow-up outpatient consultations within 90 days, and these must be provided by, or referred in writing by, the attending doctor.
• Day surgery: surgical procedures performed outside an inpatient setting (for example, at a day procedure centre), including endoscopy
• Benefit limit: under the Standard Plan, the maximum reimbursement is HK$580 per consultation, with an annual cap of HK$3,000 in total. Flexi Plans will usually offer higher cover on this basis, depending on the insurer and plan tier. 

The benefits of Voluntary Health Insurance include, in addition to basic consultation fees, coverage for “prescribed outpatient diagnostic imaging tests”. These tests include computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET Scan).

Even if these tests are carried out in an outpatient setting, as long as they are medically necessary and referred in writing by a doctor, reimbursement can generally still be claimed.

However, please note that under the Standard Plan, the insured person is required to bear 30% co-insurance for these tests.

Further reading: [Pre-existing conditions before taking out insurance] How does Voluntary Health Insurance define known and unknown pre-existing conditions?  

Voluntary Health Insurance Scheme generally does not cover ordinary day-to-day outpatient care, while under the Standard Plan, pre- and post-hospitalisation outpatient care related to hospitalisation or day surgery is also subject to limits on the number of visits and reimbursement amount. As for extended outpatient benefits such as accident and emergency treatment, dialysis or rehabilitation therapy, these are more commonly found in Flexi Plans or premium products, but the scope of cover and policy terms can vary significantly between insurers.

Therefore, when comparing plans, the key consideration is not merely whether the relevant cover is included, but how much is actually reimbursed, whether coinsurance applies, and whether the benefit is a core item or an add-on. All of these will directly affect the overall protection and tax deduction arrangement.

Through the 10Life Voluntary Health Insurance Scheme comparison platform, you can compare the scope of cover, benefit limits and policy details of different plans in one place, helping you make a clearer choice based on your own needs and budget. 

Compared with the Standard Plan, the Flexi Plan under Voluntary Health Insurance, or the High-End Plan, not only raises the reimbursement limit but also adds some extended outpatient benefits. Although these items are not part of ordinary inpatient expenses, they may be practically useful for some policyholders as they involve specific medical needs or higher costs.

Common extended outpatient items include:

• Accident and emergency outpatient treatment: 
  Covers same-day accident and emergency consultation, wound treatment and related examination fees arising from an accident 
• Outpatient renal dialysis: 
  Provides cover for regular haemodialysis or peritoneal dialysis required due to chronic renal failure 
• Post-operative rehabilitation treatment: 
  Includes specified rehabilitation services such as physiotherapy, occupational therapy or speech therapy 
• Traditional Chinese medicine treatment: 
  Some plans cover a specified number of Traditional Chinese Medicine outpatient consultations after surgery or an accident 

In addition to the outpatient items above, High-End Plans may also offer extended benefits related to recovery. For example, after major surgery, if the insured requires professional care but does not need to remain in hospital, some plans may cover home nursing expenses, with a registered nurse providing care at home.

Moreover, as day-case medical services have become more common, many procedures, such as endoscopy or cataract surgery, can now be completed on the same day. Some Flexi Plans offer a day-surgery cash benefit as an additional allowance to help offset outpatient surgery costs. 

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.