Scoring Methodology of Medical Insurance

1. Scoring Methodology at a Glance 

Medical insurance mainly covers hospitalisation expenses, and the policy is usually renewed on an annual basis. Some medical insurance products have maximum coverage limits on certain medical expense categories, while some offer “full coverage” on individual medial expense categories (subject to the costs being reasonable and customary) with an overall annual and a life time limit. 

Many consumers worry that in an unfortunate event of requiring hospitalisation at a private hospital, how much of the hospital bill their medical insurance can cover, and how much they would need to pay out of pocket. Due to the complicated structure of medical insurance products, including inner benefit limits and/or exclusions on various medical expense items, an average consumer may not be able to estimate the amount of coverage.

In order to compare the coverage of different medical insurance products, 10Life selected a number of common hospitalisation cases with different severity levels and required medical services, and consulted with a number of medical specialists on the estimated medical expenses under general circumstances. Using these assumptions, our actuaries calculated the estimated average coverage of each mass market medical insurance product to arrive at the product comparison and scores. The coverage is based on non-network doctor usage as the doctors available for each insurance panel can differ significantly.

10Life compares the medical insurance products in the market based on two main factors:

  • 10Life Medical Coverage Score – based on the coverage ratios on selected hospitalisation cases with different severity levels
  • Medical Inflation Protection – product features that help protect against medical inflation

Other factors such as underwriting process, ease of claims, and your individual needs, have not been considered. 


2. Assumptions

Insured is non-smoker, hospitalisation in Hong Kong private hospitals.

Note: The premium table shows the current prices at different ages, i.e adult or child, which do not represent prices in the future, which may increase significantly due to medical inflation.


3. 10Life Medical Coverage Score

To estimate the medical cost compositions of the different hospitalisation cases, 10Life researched into public information available, including the following sources: 

  • Reference fees and charges listed on the Hong Kong private hospital websites
  • Reference fees and charges from the Hong Kong Hospital Authority Private Service  
  • 2015 HKFI claims statistics

CategoryCase Details
CancerBreast Cancer with Mastectomy, Reconstruction, Chemotherapy & Radiotherapy
Lung Cancer with Lobectomy
Liver Cancer with Surgery and Targeted Therapy
Colon Cancer with Surgery and Chemotherapy
InjuriesAnterior Cruciate Ligament Surgery
Total Knee Replacement
Vascular DiseasesAngioplasty and Stent Placement
Stroke
Kidney Dialysis
Common CasesFever Requiring Hospitalisation
Hemorrhoid Surgery
Colonoscopy (Day Case)

To improve on the accuracy of our estimates, 10Life reached out to the claims department of several major medical insurers to obtain initial estimates of the 12 different cases. We then consulted with medical specialists in Hong Kong to verify the estimates. We also cross referenced the resulting overall costs to the public information where available to ensure reasonableness. Note that these estimates are based on normal circumstances of hospitalistaion in private hospitals (i.e. assuming no complications other than the listed conditions). 

For products with deductibles, the estimated coverage ratios are calculated without considering the deductible amount. As consumers choose a certain deductible in exchange for lower premium, they should be conscious of the resulting expected out-of-pocket shortfall amount. 10Life focusses on comparing coverage based on unexpected events, and the deductible itself does not impact the coverage limits within the product. Therefore, products with deductibles are treated as if they had no deductibles, i.e. the out of pocket expenses stated do not include the deductible amount. 

The relevant medical expense categories and the relative proportions vary under the 12 cases studied. Using these estimated costs on each case, 10Life actuaries then refer to the benefit limits on each expense category to calculate the estimated coverage amount (to be paid by the insurer) and out of pocket expenses (to be paid by the policyholder). 


Table 1: Estimated Medical Cost of Selected Hospitalisation Cases

CasesEstimated Medical Cost (HKD)
Ward RoomSemi-private RoomPrivate Room
Breast Cancer with Mastectomy, Reconstruction, Hemotherapy & Radiotherapy
799,978  949,0371,240,755
Lung Cancer with Lobectomy of Lungs275,158417,737691,695
Colon Cancer with Surgery & Chemotherapy348,984470,076697,860
Liver Cancer Requiring Surgery & Targeted Therapy482,700600,650830,150
Common Injury - Anterior Cruciate Ligament Surgery106,900158,650259,750
Severe Injury - Total Knee Replacement196,200294,700486,900
Heart Disease - Angioplasty217,813326,120541,133
Stroke95,600123,100174,100
Kidney Dialysis – Day Case316,000316,000316,000
URTI - Fever Requiting Hospitalisation21,60033,10053,700
Hemorrhoid Surgery45,60068,600113,000
Colonoscopy -Day Case18,10026,35042,850
Note:
1. It should be noted that coverage ratios are based on estimated medical expenses under normal circumstances for illustrating how a policyholder and the insurer would share the incurred medical expenses, and should not be regarded as the actual medical cost. The actual claim payment amount of each case may vary by the actual severity and medical procedures used, as well as the insurer’s claim assessments.
 2. The above information is updated as of 03-12-2021.


The Estimated Coverage Ratio of each of the 12 medical cases is calculated as follows:

Estimated Coverage Ratio = (Estimated Coverage Amount / Estimated Medical Expense Incurred) × 100%

To reflect the relativity of the various cost amounts among the 12 cases, a weighted average based on the estimated medical expense incurred for each case is calculated: 

Weighted Average Coverage Ratio = SUM of [Estimated Coverage Ratio × weight of case]

where weight of each case = Estimated Medical Expense Incurred / (SUM of [Estimated Medical Expense Incurred])

10Life Medical Coverage Score (Out of 10) = Weighted Average Coverage Ratio / 100% × 10

It should be noted that estimated average coverage are based on estimated medical expenses under normal circumstances for illustrating how a policyholder and the insurer would share the incurred medical expenses, and should not be regarded as the actual medical cost. The actual claim payment amount of each case may vary by the actual severity and medical procedures used, as well as the insurer’s claim assessment.


4. Medical Inflation Protection

In addition to the coverage ratios for the selected medical cases, 10Life has compared other features in the products that have not been reflected in the 12 medical cases. 10Life considers a product to be providing protection against medical inflation if the below criteria are met.

  1. Full coverage (no inner limit) – i.e. no maximum coverage limits on most individual medical expense categories (subject to the costs being reasonable and customary)
  2. High Annual Limit 
    • Ward: ≥ $5,000,000
    • Semi-private: ≥ $8,000,000
    • Private: ≥ $20,000,000
  3. One or both of the following 2 conditions:
    • No lifetime limit
    • Guaranteed that benefits would not be reduced at renewal (i.e. all VHIS products)

5. Number of Additional Features

In addition to the coverage ratios in the selected medical cases and medical inflation protection, a list of distinguishable additional features that can improve the overall coverage for the customer have been selected as follows.

List of Additional Features
Second Medical Opinion Service
International Assistance Service
Hospital Cash (private hospital under current room class)
Long-term Post Hospitalisation Outpatient Cover (180 days or above covering no less than 6 visits)
Hospice/Palliative Care Coverage ($80,000 or above per life)
Pregnancy Complications Coverage ($100,000 or above per policy year, or covers no less than 80% of the expense)
Short Waiting Period
VHIS Plan: ≤30 days for unknown pre-existing conditions
Non-VHIS Plan: ≤30 days for general waiting period 
Waiver on Deductible (for certain critical cases)  

6. 
10Life Medical Insurance 5-Star Ratings 

5-Star Ratings for medical insurance is based on 10Life Medical Coverage Score and Medical Inflation Protection. 5-Star Ratings are categorised by hospital room levels (Ward Room, Semi-Private Room or Private Room)

To earn a 5-Star Rating, the product must meet the criteria below.
Room Type10Life Medical Coverage Score
Medical Inflation Protection
Ward≥ 9.95
Semi-Private≥ 9.95
Private≥ 9.95

10Life strives to offer an unbiased scoring methodology to compare insurance products through data analyses and mathematical calculations, based on public information from insurers. 10Life scores are for reference only, and do not constitute any insurance sales advice. As everyone has different insurance needs and affordability levels, you should seek independent advice from licensed insurance advisors before purchasing any insurance products. 10Life may review the scoring methodology from time to time to improve the product comparisons. If you have any questions or suggestions on the methodology, please email us at enquiries@10Life.com.
 
Updated on 13 Jan, 2022





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