The following is a real customer claim case that Bowtie’s team has obtained consent from the customer to share for reference.
Mr. Chan, age 37
Plan purchased: Bowtie Critical Illness
Diagnosed with: Nasopharyngeal Cancer
Claim Amount: HK$1 million
In July 2021, Mr. Chan discovered Bowtie, a virtual insurance company, through an advertisement. Intrigued by the concept, he recognized the potential cost-effectiveness of virtual insurance compared to traditional insurance. After careful research and consideration, he decided to purchase two insurance products from Bowtie: VHIS (Standard Plan) and Critical Illness Plan (Benefit of HK$1 million).
With VHIS, Mr. Chan secured a safety net for himself. This insurance allows him to manage medical expenses on a reimbursement basis, lessening his financial burden if he were to unfortunately experience a critical illness. Additionally, the Critical Illness Plan provides Mr. Chan with a lump-sum compensation if he becomes incapable of working due to illness. This payout helps address any cash flow difficulties he may face during such challenging circumstances. Overall, Mr. Chan’s decision to purchase these insurance products from Bowtie aimed to provide him with a more solid financial foundation and peace of mind, should he encounter any critical health issues.
Soon after Mr. Chan bought insurance, his decision proved to be beneficial. In September 2022, he noticed a blockage in his left ear and promptly sought medical advice from a specialist clinic. The ear, nose, and throat doctor conducted a thorough examination using an otoscope and discovered an issue with fluid accumulation in his ear. The doctor also performed a nasopharyngeal examination using an endoscope and removed a polyp near the pharyngeal tube connected to Mr. Chan’s left ear for further analysis. A week later, the doctor delivered the diagnosis: cancer cells were found in the area where the polyp was removed. This unexpected finding shed light on the importance of Mr. Chan’s insurance coverage and the timely medical intervention facilitated by it.
To ensure the accuracy of the diagnosis, the doctor suggested that Mr. Chan undergo a magnetic resonance imaging (MRI) scan and a positron emission tomography-computed tomography (PET-CT) scan. With a sense of unease, Mr. Chan underwent these two examinations.
The results of the reports came out a few days later, confirming that Mr. Chan was diagnosed with nasopharyngeal cancer. The nasopharyngeal cancer he had was classified as stage III, indicating that the cancer cells had spread to the lymph nodes on both sides of the neck and the tumor had extended to the skull or nasal sinuses. In general, the treatment plan would involve using radiation therapy to kill the cancer cells and combining it with chemotherapy to control the extent of spread. Fortunately, after evaluating Mr. Chan’s condition, the doctor believed that his prognosis was optimistic, and as long as he received treatment early, there was a good chance of recovery.
In October 2022, while actively receiving treatment for nasopharyngeal cancer, Mr. Chan proceeded to file a claim for critical illness coverage with Bowtie. Upon receiving the claim, Bowtie’s claims team initiated the assessment process by requesting medical records from the various healthcare institutions where Mr. Chan had sought treatment, including public hospitals, private hospitals, and clinics. These records were necessary to support the evaluation of his claim.
Since Mr. Chan had received treatment at Queen Mary Hospital, the claims team followed the established procedures to obtain medical records reports from both the Hospital Authority and Queen Mary Hospital. By February 2023, Mr. Chan had completed approximately 40 sessions of radiotherapy and chemotherapy, resulting in successful control of his nasopharyngeal cancer.However, during the review of his medical records reports, Bowtie discovered that Mr. Chan had visited a clinic in 2019, two years prior to applying for the insurance plans, for diabetes-related treatment. It came to light that Mr. Chan had not disclosed this pre-existing health condition when completing the health questionnaire during the underwriting process. Given that the presence of diabetes could potentially impact the underwriting decision, the claims team decided to re-evaluate Mr. Chan’s case in March 2023.
Finally, based on the medical history recorded by that clinic, it showed that Mr. Chan had sought treatment and was diagnosed with diabetes from 2017 to 2019. This had a significant impact on the underwriting decision made by Bowtie in 2021. The team had no choice but decided to withdraw the two underwriting decisions made in 2021.
When the colleagues from Bowtie’s claims team informed Mr. Chan of this decision and explained the reasons behind it, he felt thunderstruck. He had thought he would be eligible for a claim of 1 million, but now he not only received nothing but also had his two policies cancelled.
In fact, we understand that there can be differences between a patient’s understanding of their own medical condition and the diagnosis made by doctors. Considering that Mr. Chan may not have had full access to his complete medical history and that the medical records from the clinic may not have been comprehensive, we understand that he may have had the opportunity to confuse his medical history or may not have fully understood certain medical terms. Therefore, Bowtie’s Claim specialist suggests Mr. Chan to make an appeal, seek legal advice to address his concerns and explore any possible recourse available to him, so that Mr. Chan wouldn’t lose the compensation due to misunderstanding regarding his medical history in underwriting.
In any situation, policyholders should adhere to the principle of utmost good faith and honestly disclose their health conditions. Failure to do so can potentially affect future claims and even render the entire policy invalid, resulting in loss. If there are any doubts or questions while filling out a health questionnaire, it is advisable to contact Bowtie’s customer service representative for assistance.
Mr. Chan, in his appeal application, stated that he had no intention of concealing any significant facts. He clearly remembered that the doctor at the clinic explicitly told him that his condition was only “pre-diabetes,” which did not constitute diabetes according to the definition. That’s why he did not declare the condition when filling out the health questionnaire. The claim team has the responsibility to thoroughly investigate the incident based on Mr. Chan’s appeal application. Upon receiving this explanation, the claims team decided to follow up with the doctor at the clinic regarding Mr. Chan’s health condition, hoping to understand whether he was medically diagnosed with diabetes and whether the clinic’s medical records were accurate.
Unlike other insurance companies in the market that communicate with customers through agents, Bowtie places great importance on customer experience, especially direct communication with customers. In the case of Mr. Chan, colleagues from the claims team directly explained to him the basis for the claims approval decision made by the team, ensuring that Mr. Chan knew that Bowtie took into consideration the factor of “the insured having diabetes.” Therefore, when Mr. Chan decided to appeal, the claims team could collect data more specifically to provide him with a prompt response.
During the new round of investigation, the claims team discussed the case multiple times with the company’s internal medical team, aiming to verify from Mr. Chan’s medical records that he was never formally diagnosed with diabetes. They also proactively contacted the doctor at the clinic, hoping to obtain the most accurate first-hand information from that doctor. After two weeks, the claims team received written documents filled out by the doctor at the clinic, stating that Mr. Chan was indeed not formally diagnosed with diabetes before 2019. However, the latest data indicated that Mr. Chan had a condition of “abnormal liver function”.
In the end, the medical team agreed to accept the doctor’s information, and Bowtie decided to re-examine the initial underwriting decision. With reference to the latest medical records and after several internal meetings, the claims team collected sufficient data to support our claims approval decision. However, considering Mr. Chen’s medical history of “abnormal liver function”, it was decided, in accordance with the company’s internal guidelines, to adjust the premiums for his existing VHIS plan and the Critical Illness plan with a benefit of 1 million. The premiums were increased by 75% and 50%, respectively. On the other hand, due to the sufficient medical records confirming Mr. Chan’s diagnosis of stage III nasopharyngeal cancer, the team approved the claim for One million in accordance with the terms of the critical illness plan.
When considering each appeal application, Bowtie’s claims team takes into account the individual customer’s circumstances in order to make a decision. However, it is important to note that this does not imply or guarantee that similar cases in the future will receive the same arrangement.
Bowtie understands the underwriting questionnaire may be a bit confusing for some of the customers. And there are chance customers could mix up their “medical record”, do not have thorough understanding on “Medical Terms”, therefore, we used day-to-day language in underwriting questionnaires, so that customers could disclose their health conditions accurately.
From the underwriting perspective, we understand that customers may not have thorough idea on what disease The Insured Person is suffering, therefore we use simple terms while designing the questions, such as : “Have you ever been diagnosed with any of the following diseases or medical conditions?” or “have you ever had or been advised to have any regular or ongoing follow-up consultations or medical care with a healthcare professional for any disease or medical condition?”
Take “diabetes” as an example, this is how our underwriting question in Critical Illness is designed:
If the customer replies “yes” or show uncertainty during the questionnaires, we would ask for more information, such as:
We have also taken reference from the “Best Practice on Standardizing Underwriting Questionnaire for Individual Indemnity Hospital Insurance Plans” from The Hong Kong Federation of Insurers, in order to help our customers to report their health condition accurately.
Bowtie has a significant number of customers who hold different types of insurance policies simultaneously. Different types of insurance products generally have their own individual claims assessment procedures across the insurance industry. Our approach aligns with industry standards among insurance companies (including reinsurers). Bowtie has always adhered to the principle of fairness and justice in serving our customers, and we use this principle as a reference when reviewing the information and medical reports provided by customers. We consider various factors to conduct detailed underwriting and handle claims applications for different products.
When processing a claim case, Bowtie reviews the information provided by the customer and the relevant medical documents submitted. We conduct a detailed review based on various considerations. During the process, Bowtie may decide whether it is necessary to request further medical documents from the relevant medical institution to assist us in making a claims decision. The policy term is just one of the considerations and not the sole determining factor. Through comprehensive evaluation, we aim to ensure that customers receive fair and just outcomes.
Furthermore, to avoid potential disputes in future claims applications, Bowtie actively provides claims guidance to customers and offers various articles and real customer claims cases to provide customers with different claims information.
Based on Bowtie’s claims data from the past twelve months, 99.7%* of the claims application are successful.
*This includes all insurance products, including group medical insurance plans.
With the advancement of medical technology, people have access to state-of-the-art diagnostic tools, allowing for early detection of diseases and preventing minor illnesses from becoming major ones. Treatment plans have also become more precise, greatly improving patients’ survival rates. Additionally, insurance plans such as VHIS and Critical Illness help alleviate the financial burden on policyholders, reducing their psychological stress and enabling them to focus on their treatment.
To ensure fairness to policyholders and the sustainability of products, Bowtie has established a comprehensive and equitable claims mechanism. The aim is to ensure that eligible policyholders receive the appropriate coverage, adhering to the principle of “pay if it should be paid, and fully compensate if eligible”.
We are committed to doing better and more for you. Whether it’s pre-admission claims estimation, hassle-free discharge settlement, or post-discharge claims procedures, we are more than happy to answer any questions you may have and provide timely assistance to put your mind at ease during your treatment. Just give us a call, and we will do our best to assist you and ensure a smooth claims process!
Learn about Claim Procedure
CS Hotline: 3008 8123
Claim Specialist Hotline: 3001 5670