An “exclusion” is a condition, event, or action that is not covered by the insurance policy. For health insurance, most exclusions are related to body organs, illnesses, treatments, and medications, etc. Under no circumstances will the insured be able to make a claim against the insurance company for the expense of those exclusions.
In general, the exclusions are listed with defined terms in the insurance documents, such as brochures, promotional materials, and the terms and conditions of the insurance policy. It is also the responsibility of the agents and brokers entrusted by the insured to explain the details. Of course, the situation varies from person to person, and after the underwriting process of the insurance company, the “exclusions” on the policy may be increased and may turn out to be “additional exclusions”.
It is worth noting that some insured persons with “special” physical conditions may even be declined or temporarily declined from coverage after the underwriting process.
Since all the insured persons of the same plan are claiming from the same pool of funds, it would be unfair to other insured if some have a greater chance of making a claim due to their own circumstances. Therefore, in order to balance the risk, the insurance company has to take measures such as adding terms like “exclusion”, “declination” or ” temporarily declined”.
The Voluntary Health Insurance Scheme (VHIS) is launched by the Food and Health Bureau. Insurance companies are required to obtain approval from the authority and meet certain standards when the product is released. Key exclusions of the VHIS are as follows:
For example, If the insured person is suffering from upper abdominal discomfort and arranges for a gastroscopy to check for abnormality by himself without any referral or advice from a medical practitioner. It is likely that this test will be considered “non-medically necessary” and not covered. It is important to note that the cost of gastroscopy will be reimbursed if there is a medical necessity!
Allied healthcare services include physiotherapy, occupational therapy, and speech therapy. Generally, these treatments do not require hospitalization (excluding special circumstances recommended by the practitioner). However, if the insured person is hospitalized before or after receiving allied healthcare services, there is a chance that he or she will not receive any reimbursement from the insurance company for the cost of the hospitalization.
If the insured person suffered AIDS (one of the HIV-related diseases) before the effective date of the policy and makes a claim for medical expenses, the insurance company will not pay the claim. In case the disease occurs within 5 years after policy issuance (but the time of the first infection cannot be verified), the insurance company will also assume that the insured person had AIDS before the effective date of the policy, and in such case, no claim will be paid.
The above does not apply to cases of sexual assault, medical assistance, organ transplants, blood transfusions or donations, or HIV infection at birth. Reimbursement will be made in accordance with the insurance company’s terms and other terms in the policy.
Assume that the insured person is addicted to drugs and has developed clinical symptoms such as urinary frequency, urinary urgency, painful urination, hematuria, urinary hesitancy, and urinary incontinence due to the use of ketamine, and subsequently seeks medical treatment for these symptoms, the insurance company will not pay for these expenses.
The cost of breast augmentation, rhinoplasty, etc. for the purpose of improving aesthetic appearance will not be covered. However, breast reconstruction surgery or any other plastic/cosmetic surgery performed under the instruction of a doctor due to breast cancer, or due to an accident, is not included in this exclusion. For breast reconstruction surgery after an accident, the surgery would only be covered if it is necessitated by an injury caused by an accident, and the Insured Person receives the Medical Services within 90 days of the Accident.
Many Hong Kong people suffer from myopia, astigmatism, and presbyopia, which are all regarded as “refractive errors”. All optometric services, such as eye examinations, eyeglasses, and even laser vision correction, are not covered.
For health and early detection of illnesses, some people in Hong Kong have regular annual/semi-annual body checks. However, no claims will be paid for these check-ups regardless of where they are done (in hospitals, clinics or day centres).
It is recommended that at least one dental scaling should be performed annually, and the process of scaling will probably involve filling, teeth whitening and orthodontic services. These services are not covered.
For example, no coverage will be given for sterilization procedures performed after marriage for the reason of not wanting children.
The purchase of different types of medical equipment and devices for medical conditions, such as glasses for short-sightedness, wheelchairs for mobility problems, and respiratory pressure machines for lung disease, will not be covered. Medical equipment and devices include, but are not limited to, wheelchairs, beds and furniture, respiratory pressure and masks, portable oxygen and oxygen therapy devices, haemodialysis machines, exercise equipment, eyeglasses, hearing aids, special braces, walking aids, non-prescribed medications, air purifiers or air conditioners for home use, and heating devices.
However, this does not apply to medical equipment and devices rented during the hospitalization or day surgery.
The scope of traditional Chinese medicine treatment is extensive. In addition to herbal treatment, there are also bone-setting, acupuncture, acupressure, and tui-na massage, etc. There are also many alternative treatments, such as hypnotherapy, qigong, massage, aromatherapy, etc. However, all Chinese medicine treatments are classified as exclusions.
If you have a family member or friend who had cancer, you may have heard that they were invited to participate in experimental treatment at a hospital/university. Generally, the experimental treatment would be free, but if there is a cost involved, the cost will not be reimbursed.
This refers to any medical, physical, or mental abnormality that existed at or before birth, whether or not the abnormality was present, diagnosed, or known at birth; or any neonatal abnormality that occurred within 6 months of birth.
Suppose you are covered by both group medical insurance (a product of Insurance Company A) and your own VHIS (a product of Insurance Company B). After receiving treatment, you first file a claim with one of these two insurance companies and are fully reimbursed, and then file a claim with the other company. You will not receive payment for this repetitive claim for the same medical expenses.
There is no doubt that there is a chance of losing limbs or body parts due to damage caused by gunfire in war. However, VHIS does not cover the cost of the relevant treatments, because all medical expenses incurred as a result of war are excluded from coverage.
When comparing the Voluntary Health Insurance Scheme with other health insurance plans, you will realize there are fewer exclusions in VHIS than general health insurance. The following are the general exclusions for some plans in the market:
Although all VHIS plans are authorized by the Food and Health Bureau, exclusions are not standardized. If the insured is diagnosed with certain diseases or has other health risk factors such as smoking habits, family history, or occupational disease risk, the insurance company may add additional exclusions for individual conditions.
When the insurance company adds additional exclusions, it must amend the Standard Terms and Conditions and/or Standard Schedule of Benefits, or add a supplement, and must clearly define the rights and obligations of the policyholder/insurer involved.
Since the Food and Health Bureau regulates the sample policy for authorized products, the definitions of exclusions are generally the same. However, as mentioned above, insurance companies can add additional exclusions and revise policy documents for different clients, so the definitions of these exclusions may vary.
As mentioned at the beginning of the article, insurers include “exclusions” to balance the risk, and “loading” is another measure that can “replace” exclusions while balancing the risk effectively.
“Loading” refers to the payment of an add-on premium to reinstate coverage for the original exclusion. Once the policy is in force, the insured can file an appeal on the additional premium if he/she does not suffer from the physical condition/illness of the exclusion anymore. Of course, the above-mentioned measures may not be applicable to all insurance companies, plans and exclusions.
The Food and Health Bureau does not impose many restrictions on the VHIS regarding additional premiums. The decision to charge additional premiums is left to the discretion of the insurance companies.