What Are Exclusions in VHIS? Definition, list and comparsion with medical insurance
What are "Exclusions"?
“Exclusion” refers to situations, matters, or actions not covered by an insurance policy. In the context of medical insurance, exclusions mostly pertain to specific body organs, diseases, treatments, or medications. Even if the policyholder submits a claim for expenses related to such matters, no compensation will be provided under any circumstances.
Exclusions are generally listed with their definitions in insurance documents, such as brochures, other promotional materials, and the insurance terms and conditions. The agent or broker appointed by the policyholder is also responsible for explaining these to the client. Of course, each individual’s situation varies, and after the insurance company’s underwriting process, the “exclusions” on a policy may increase, becoming “additional exclusions.”
Exclusions in VHIS
The Voluntary Health Insurance Scheme (VHIS) is implemented by the Health Bureau . Insurance companies must obtain the Bureau’s accreditation and meet certain standards when launching products.
General exclusions under VHIS are as follows:
- Any non-medically necessary treatment/medication/tests or services
For example, if an insured person experiences upper abdominal discomfort and arranges a gastroscopy on their own to check for abnormalities in their stomach. Without a doctor’s referral or recommendation, this examination is likely to be considered a “non- medically necessary ” test and therefore not eligible for compensation. It is worth noting that if there is a medical need, gastroscopy costs can be reimbursed!
Allied health services include physiotherapy, occupational therapy, and speech therapy . Generally, these treatments do not require hospitalisation (excluding special circumstances recommended by a doctor). However, if an insured person is hospitalised while receiving allied health services and subsequently claims hospitalisation costs from the insurance company, compensation may be denied.
If an insured person was already suffering from AIDS (one of the HIV-related diseases) before the policy effective date and claims related medical expenses from the insurance company, no compensation will be provided. If the disease manifests within 5 years from the policy effective date, but the time of initial infection cannot be proven, the insurance company will also consider the insured person to have contracted AIDS before the policy effective date, and no compensation will be provided in this situation.
Of course, the above situations do not apply to AIDS contracted due to sexual assault, medical assistance, organ transplant, blood transfusion or donation, or at birth. Related compensation will be handled according to the insurance company’s terms and other policy provisions.
Suppose an insured person is addicted to drugs and develops clinical symptoms such as frequent urination, urgency, painful urination, hematuria, difficulty urinating, and urge incontinence due to ketamine use (commonly known as “K-仔”). If they seek medical attention for these symptoms and subsequently claim medical expenses from the insurance company, these expenses will not be reimbursed.
If an insured person undergoes breast augmentation, rhinoplasty, or other surgeries for aesthetic purposes, the costs will not be reimbursed. However, breast reconstruction surgery performed under a doctor’s guidance due to breast cancer or an accident, or other reconstructive/plastic surgeries, are not included in this exclusion.
Many Hongkongers suffer from myopia , astigmatism , and presbyopia. These eye conditions are all considered “refractive errors.” All vision-related services, such as eye exams, glasses prescription, and even laser vision correction , are excluded.
To maintain health and detect physical ailments early, some Hongkongers undergo regular health check-ups once a year or every six months. Regardless of whether the check-up is performed in a hospital, clinic, or day centre, it will not be reimbursed.
Dentists recommend teeth cleaning at least once a year. Services involved in the teeth cleaning process, such as fillings, teeth whitening, and orthodontics, are not covered.
For example, sterilisation surgery performed after marriage due to the desire not to have children will not be compensated.
People with myopia need glasses, those with mobility issues need wheelchairs, and those with lung disease may require respiratory pressure machines. However, the purchase of various types of medical equipment and devices due to illness will not be reimbursed. Medical equipment and devices include, but are not limited to, wheelchairs, beds and furniture, respiratory pressure machines and masks, portable oxygen and oxygen therapy equipment, hemodialysis machines, exercise equipment, glasses, hearing aids, special braces, walking aids, over-the-counter medications, home air purifiers or air conditioning and heating devices.
However, medical equipment and devices rented during hospitalisation or on the day of day surgery are not subject to this exclusion.
Sometimes, when experiencing prolonged discomfort, one might seek a Chinese medicine practitioner for “conditioning.” The scope of traditional Chinese medicine treatment is indeed broad, including herbal medicine, bone-setting, acupuncture , acupressure, and Tui Na. There are also many alternative therapies, such as hypnotherapy, Qigong, massage, and aromatherapy. However, all Chinese medicine treatments are listed as exclusions.
If you have family members or friends who have suffered from cancer , you might have heard of them being invited to participate in experimental treatments at hospitals/universities. Although experimental treatments are generally free, if any costs are involved, these expenses will not be reimbursed.
Exclusions Comparison: VHIS vs General Medical Insurance
When comparing VHIS and other medical insurance plans, you will find that VHIS has fewer exclusions than general medical insurance plans. Below are some common exclusions for certain medical insurance plans on the market:
- Congenital conditions
- Pre-existing conditions / Unknown Pre-existing Conditions
- Day Surgery , including Endoscopy
- Inpatient psychiatric treatment
| Medical Condition / Procedure | VHIS | General Medical Insurance |
| Congenital conditions | ✔ 1 | ❌ |
| Unknown pre-existing conditions | ✔ 2 | |
| Day surgery | ✔ | |
| Coverage for outpatient prescribed diagnostic imaging tests
(CT, MRI, PET scans, etc.) |
✔ | |
| Inpatient psychiatric treatment | ✔ |
- 1Covers the detection and treatment of congenital conditions that appear or are diagnosed after the insured reaches 8 years of age.
- 2Bowtie VHIS Standard has a waiting period for "unknown pre-existing conditions". The first policy year is the waiting period, partial coverage begins in the second policy year (25% in the second year, 50% in the third year), and full compensation (100%) is provided from the fourth policy year onwards.
Exclusions Arising from Underwriting
It is worth noting that if an applicant has a ‘special’ medical history or pre-existing conditions, after the insurer’s underwriting process, the approved policy may have additional ‘exclusions’ (or an extra premium, commonly known as ‘loading’). For more severe cases, the insurer may even directly decline or temporarily suspend coverage.
For example, Ms. A, with a history of uterine-related conditions, applied for a VHIS plan with an insurer. After the underwriting process, the insurer decided to approve her policy but added an ‘exclusion’ specific to Ms. A’s medical history, in addition to the general VHIS exclusions. The policy stipulated that her uterine diseases / uterine-related medical conditions would not be covered by that policy.
Insurers make such decisions after underwriting primarily because all clients insured under the same medical insurance plan claim from the same fund pool. If some insured individuals have significantly higher claim risks due to their health conditions, it will directly affect the common interests of all policyholders. To maintain fairness, insurers control risk by adding ‘exclusions’.
Can Loading Fees Remove Additional Exclusions?
As mentioned at the beginning of the article, insurers add ‘exclusions’ to balance risk, and ‘loading’ is another effective measure that can ‘replace’ exclusions and balance risk.
‘Loading’ means paying an additional premium to regain coverage for previously excluded conditions. After the policy takes effect, if the policyholder no longer experiences the health conditions/diseases related to the exclusion, they can appeal to have the additional premium waived. Of course, the measures mentioned above may not apply to all insurers, plans, and exclusions.
The Health Bureau also does not impose significant restrictions on additional premiums for VHIS plans; the decision to charge additional premiums is at the discretion of the insurer.
Are VHIS Exclusions Standardized Across All Plans?
Although all VHIS plans are launched with the approval of the Health Bureau, exclusions are not standardized. If a client has been diagnosed with certain diseases at the time of application, or has other health risk factors such as smoking habits, family medical history or occupational disease risks, the insurer may add other exclusions for specific conditions.
When an insurer adds additional exclusions, it must amend the ‘Standard Terms and Conditions’ and/or ‘Standard Benefit Schedule’, or include supplementary documents, and must clearly define the rights and obligations of the policyholder/insurer.
Since the Health Bureau regulates the templates for approved product policies, the definitions of general exclusions are usually the same.
However, as mentioned above, insurers can add additional exclusions based on different client situations and amend policy documents, so the definitions of these matters may differ.
Bowtie offers various Voluntary Health Insurance Scheme plans, and the definition of exclusions is the same for every plan.
