Consumers are urged to pay attention to the provisions and exclusions in small print which are equally important, if not more, in addition to the premium and scope of cover in the choice of medical insurance plan.
Last year the Consumer Council received 61 consumer complaints related to medical insurance. Over half of these complaints concerned claims and premium disputes.
Highlighted in the latest issue of CHOICE are some of the complaints commonly faced by consumers when filing claim under medical policies.
Case 1
A complainant underwent an operation on his ankle at a public hospital and was later transferred to another public hospital for treatment. His hospitalization claim was rejected by the insurance company on the ground that the second hospital he was admitted did not comply with the definition of "hospital" stipulated in the policy.
Consumers should pay attention to the specific definitions of "hospital" stipulated in the policy.
Case 2
A complainant's claim on surgical expenses was rejected by the insurance company as he failed to disclose important medical history before signing up the policy. However, the complainant argued that it was unreasonable to consider gastroenteritis and hyperlipidemia as important medical history, and questioned why these two conditions were not listed in the proposal form if they were important.
Case 3
A complainant purchased an insurance policy that offer lifetime protection for life, accident, sickness, and hospital and surgical benefits. After five years into the contract he was notified by the insurance company that the original hospital and surgical benefit would be terminated and he could choose another plan but the annual premium would be increased by HK$1,000.
The complainant said the highlights on the promotion leaflet of that particular plan included "Lifetime Protection" and "guaranteed renewable up to age 100", and he was attracted by these claims into purchasing the hospital and surgical benefits.
The insurance company argued that promotional leaflets were for reference only. According to the clauses in the medical insurance policies, the insurance company had the rights to notify the policy holders about the changes in premium and benefit coverage upon policy renewable, as long as the notifying period was no less than 30 days.
Consumers are advised to pay special attention to the following:
- Study the policy carefully and pay particular attention to the exclusion clauses, conditions for renewal, definitions and restrictions, and if in doubt, seek clarification.
- The disclosure of medical history is of the utmost importance. This is the responsibility of an applicant when applying for medical insurance cover. Fill out the proposal form with great care to ensure that all important information, in particular the medical history. Otherwise, insurance companies may use the excuse of covering up the medical history and deny the claims of unrelated conditions.
- All policies contain a provision of "waiting period" which means that no indemnity will be paid for medical expenses incurred within certain period of time after the inception of the policies. The waiting period for some illness could be up to one year.
- Be wary of the illnesses and conditions not included in the covered items of policies. These exclusions commonly included pre-existing and related conditions, congenital and hereditary conditions.
The insurance sector also has an active role to play to eliminate claim disputes:
- Provide the consumers with detailed policy at the point of sales, and clarify the important terms and conditions, definitions etc.
- Avoid stating phrases or claims in promotion leaflets that might cause misunderstanding.
The Council supports the proposed establishment of an independent insurance authority as it would improve the monitoring structure, and thus enhance the protection to existing and future insurance policy holders.
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