Author
Bowtie Team
Updated on
2025-06-19
Disclaimer: This article is translated with the assistance of AI.
Buying insurance is all about protecting yourself and your loved ones, but what happens when your claim doesn’t cover enough? You might end up paying extra out of pocket or even dealing with insurers legally. Discover the key reasons for insufficient claims and smart solutions beyond appeals to get the support you deserve.
5 Major Reasons for Insufficient Insurance Claims
Insufficient Policy Coverage
Even if you’ve bought medical insurance, you might still have to cover some costs yourself when you need hospitalization or surgery. Different medical policies vary greatly in their coverage scope and limits, so not every policy can achieve 100% reimbursement—especially for entry-level ones like the Bowtie VHIS Standard, where the reimbursement rate for complex surgeries might only be 30-50%.
If you want to avoid falling short on claims due to inadequate policy coverage, consider opting for plans with higher coverage, such as the Bowtie VHIS Flexi Plan or premium VHIS products, when you purchase your policy.
Policy Deductibles or Co-Insurance
Some medical policies include deductibles (commonly known as Deductibles ), for example, premium VHIS plans that offer full reimbursement without per-item limits. Take Bowtie Pink, which provides deductible options of HK$0, HK$20,000, HK$50,000, and HK$80,000, allowing policyholders to choose based on their existing insurance or company plans to avoid overlaps and save on premiums.
Additionally, many medical policies have a co-insurance mechanism for certain coverage items, meaning the insured must pay a percentage of the costs themselves (typically 5-30%). For VHIS, for instance, diagnostic imaging tests like CT, MRI, PET scans and supplementary medical coverage (SMM, only for the Bowtie VHIS Flexi Plan) include co-insurance, where the insured covers 30% and 20% respectively of the costs.
Not Meeting Claim Eligibility
If medical expenses don’t meet the policy’s definition of “medically necessary,” the insurer might deny the claim or only partially reimburse it, leading to insufficient coverage. For example, if you’re admitted for tests or procedures without symptoms—just for screening purposes—these might not qualify as medically necessary, giving the insurer the right to reject the claim.
To avoid ending up with an incomplete claim, it’s best to communicate with your insurer and get confirmation before hospitalization.
Failing to Apply for the Claim on Time
Insurers typically set deadlines for claim applications, ranging from 30 to 90 days depending on the company. You must submit your claim before this deadline, or the insurer can refuse it.
If you’re delayed due to illness or other reasons, explain the situation to the insurer— they’ll often consider it and handle it discretionarily if you have a reasonable explanation.
Pre-Existing Conditions Before Policy Purchase
Traditionally, pre-existing conditions before purchasing a policy are not covered, and insurers can deny claims for them. With VHIS, this has been somewhat relaxed for “unknown pre-existing conditions.” For the Bowtie VHIS Standard, for instance, in the first year, insurers only reimburse 0% of the sum assured; 25% in the second year; 50% in the third year; and 100% from the fourth year onward.
If you’re worried that restrictions on “unknown pre-existing conditions” might lead to incomplete claims, consider VHIS Flexi Plans, which generally have shorter waiting periods. For example, with the Bowtie VHIS Flexi Plan series or Bowtie Pink, the waiting period is just the first 180 days after the policy starts, and from day 181, you get 100% reimbursement based on the sum assured.
Can the Beneficiary Appeal Compensation Decisions?
Appeal to the Insurance Company
If you’re dissatisfied with the compensation result, you can first reach out to the insurance company. Clearly explain your opinions and suggestions on the outcome, and prepare all necessary supplementary documents or evidence to request a review or re-approval.
Complain to the Insurance Complaints Bureau
If you’ve already appealed to the insurance company but feel the process was unfair or their response is unacceptable, you can make a complaint to the Insurance Complaints Bureau.
The Insurance Complaints Bureau can help resolve monetary disputes (up to HK$1.2 million) arising from personal insurance contracts with insurance companies.
Disputes that can be referred to the bureau include cases where an insurance company denies part or all of a claim because it’s outside the policy’s coverage, terms, or exclusions, or where they cancel the policy due to non-disclosure of key information or false statements.
Pursue Legal Action
If you’ve gone through the above channels but still aren’t satisfied with the result, and you believe the insurance company’s denial of part or all of the claim is against the law, or if the dispute exceeds the bureau’s HK$1.2 million limit, you might consider taking legal action. This could involve filing a civil suit in the Small Claims Tribunal, District Court, or High Court of Hong Kong against the insurance company.
Are Bowtie Insurance Claims Adequate?
Since buying insurance can sometimes lead to situations where claims fall short, how does it work with Bowtie insurance?
In fact, Bowtie has handled over 70,000 claim cases since its inception, with an overall claim approval rate * as high as 99.53%,
and an average processing time # of just 4.4 working days. We get it—clients worry most about insurance that promises coverage but doesn’t deliver, or claims that don’t quite cover what’s needed. That’s why we’re all about transparency, sharing our claim stats so you can get a clearer picture of how different voluntary health insurance plans perform.
- * As of February 24, 2024, this includes the claim approval rate for all Bowtie insurance products, including group medical plans.
- # As of March 2024, the average processing time for Bowtie claim cases is 4.4 working days. This may vary depending on the complexity of the case, waiting for medical reports, or other supplementary documents.
Worried About Insufficient Claims? Choose Bowtie Pink!
As mentioned above, insufficient coverage levels in medical insurance policies are one of the reasons for ‘inadequate claims’. To get sufficient coverage without any worries, consider Bowtie’s premium Voluntary Health Insurance Scheme — Bowtie Pink . This plan offers medical coverage with no sub-limits on benefits and full reimbursement ^ .
Depending on the ward level plan, Bowtie Pink provides annual and lifetime coverage up to HK$20,000,000 and HK$80,000,000 respectively, with deductible options of HK$0, HK$20,000, HK$50,000, or HK$80,000. This allows for simple configuration to top up company medical insurance or other policies, making it easier to achieve a 100% claim reimbursement rate.
How to Choose the Deductible?
You can decide the deductible based on the ward and meal coverage amounts specified in your existing company or other medical insurance policies. Below is a reference for the premiums of Bowtie Pink for various ward levels:
Bowtie Pink (Ward)
| Existing Company/Personal Medical Insurance Ward and Meal Coverage Amount | Deductible (Excess) | Monthly Premium ( 30-year-old non-smoker) |
| Less than HK$600 | HK$20,000 | HK$321 |
| HK$600 – HK$800 | HK$50,000 | HK$220 |
| More than HK$800 | HK$80,000 | HK$197 |
Bowtie Pink (Semi-Private)
| Existing Company/Personal Medical Insurance Ward and Meal Coverage Amount | Deductible (Excess) | Monthly Premium ( 30-year-old non-smoker) |
| Less than HK$1,500 | HK$20,000 | HK$440 |
| HK$1,500 – HK$1,800 | HK$50,000 | HK$335 |
| More than HK$1,800 | HK$80,000 | HK$289 |
Bowtie Pink (Private)
| Existing Company/Personal Medical Insurance Ward and Meal Coverage Amount | Deductible (Excess) | Monthly Premium ( 30-year-old non-smoker) |
| Less than HK$4,300 | HK$20,000 | HK$1,042 |
| HK$4,300 – HK$5,300 | HK$50,000 | HK$612 |
| More than HK$5,300 | HK$80,000 | HK$537 |
- ^ Full reimbursement means there are no sub-item reimbursement limits and it only applies to specified coverage items. The payable reimbursement is subject to the deductible balance (if applicable), annual coverage limit, lifetime coverage limit, and other factors including reasonable and customary charges, pre-existing conditions, designated hospitals in Mainland China, and related matters for treatment in the US. For detailed product terms and conditions, product risks, and exclusions, please refer to the relevant product website and policy.
Bowtie VHIS Claims Procedure
If you have Bowtie VHIS and need to Claim Insurance , customers simply need to submit all claims online, and a claims specialist will follow up on the case, assist with reimbursement estimates, and provide claims progress updates. The Claims Procedure is very straightforward. Here are the steps required to claim Bowtie VHIS:
1. Initial Assessment Before Treatment/Check-up
Before undergoing treatment or checks, get a reimbursement estimate to better budget for your medical expenses.
- Download the Claim Estimation Form and have your doctor fill it out
- Log in to your Bowtie account to upload the form
- The Bowtie claims team will follow up for you, usually with results in 4-6 working days.
The estimate amount depends on the information provided by your doctor; the result is just a preliminary assessment and does not represent the final reimbursement amount.
2. Gather Required Documents
After completing treatment, remember to have your healthcare provider fill out and gather the original copies of the following required documents.
- The claims application form completed by your doctor
- Medical receipts
- Examination reports (if any), such as surgery reports, lab reports, CT scans, imaging reports
- Other supplementary documents, such as referral letters from your primary doctor or reimbursement estimates/details from other insurance companies (if you are claiming from other insurers)
3. Submit Claims Online
You can submit claims anytime, anywhere online.
- Log in to your Bowtie account to apply for claims
- Answer a few questions about the illness or injury
- Submit your bank details
4. Wait for Approval Results
The time required for each case varies depending on its complexity, but we will follow up and process it as quickly as possible.
As of March 2024, the average processing time for Bowtie claims cases is 4.4 working days. (Processing time may be affected by the actual complexity of the case, waiting for medical reports, or other supplementary documents)
Bowtie will notify you of the approval results via email. You can also log in to your Bowtie account at any time to check the claims progress.
5. Receive Reimbursement
Once approved, the reimbursement amount will be transferred to your specified bank account within 3 working days.
How to Use the ‘Discharge Without Payment’ Service?
- Complete the Pre-Approval Form and upload it to the Bowtie online platform at least 5 working days before hospital admission/treatment, or have the hospital submit it for you
- After approval, Bowtie will notify you of the results (whether successful and the reimbursement amount) via email and text message, and issue a ‘Payment Guarantee’ to the hospital
- At registration, simply inform the hospital that Bowtie has issued a ‘Payment Guarantee’ for the patient, and provide (1) proof of identity and (2) admission/treatment date
- After treatment is completed, the hospital will submit the medical bills directly to Bowtie, and Bowtie will pay the approved medical expenses on your behalf
- If the medical expenses exceed the eligible reimbursement amount, you will need to pay the difference at discharge. Please keep the receipt, as you can apply for the excess claim on the Bowtie online platform
Interested in learning more, or have some questions in mind?
WhatsApp us to save the discount code / contact our Bowtie product specialists!
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