Exclusions are usually listed along with their definitions in the insurance policy documents such as brochures, other promotional materials, and terms and conditions. The insurance agents and brokers are also responsible for explaining them to customers. Of course, each person’s situation is different, and after the insurance company’s underwriting process, more exclusions may be added to the policy.
It is worth noting that if some insured persons have had “special” conditions, their application may even be rejected or temporarily rejected after the underwriting process.
Since all customers under the same insurance plan claim from the same pool, if some individuals are more likely to claim due to their own circumstances, it may be unfair to other insured persons. Therefore, insurance companies need to take measures such as adding extra exclusions, or rejecting the policy to balance risks.
Exclusions in VHIS
VHIS is launched by the Health Bureau. Under the regulation of the scheme,insurance companies need to obtain approval from the authorities and meet certain standards when launching products.
The general exclusions for VHIS are as follows:
1. Treatments, procedures, medications, tests or services which are not Medically Necessary
For example, if the insured person has upper abdominal discomfort and wants to arrange an examination to see if there are any abnormalities in their stomach through a gastroscopy without a doctor’s referral or recommendation, this test is likely to be considered “not medically necessary,” and therefore not covered.
However, if there is a medical need, the cost of gastroscopy can be reimbursed!
2. Confinement solely for the purpose of diagnostic procedures or allied health services*
Professional medical services include physiotherapy, occupational therapy, and speech therapy. Generally, receiving such treatments does not require hospitalization (except for special circumstances recommended by a doctor), but if the insured person is hospitalized when receiving professional allied health services, and subsequently claims the expenses from the insurance company, they may not be reimbursed.
3. Treatment of Human Immunodeficiency Virus (“HIV”) and its related disability, which is contracted before the Policy Effective Date or within 5 years after policy issuance#
If the insured person suffered from AIDS (one of the diseases related to HIV) before the effective date of the policy and claims relevant medical expenses from the insurance company, they will not be reimbursed.
If the disease is contracted within five years from the effective date of the policy, but the time of initial infection cannot be proven, the insurance company will also regard the insured person as having already contracted AIDS.
Of course, the above situation does not apply to cases of sexual assault, medical assistance, organ transplant, blood transfusion or donation, or HIV infection at birth. Reimbursement for these cases will be handled according to the terms and other provisions of the insurance company.
4. Dependence, overdose or influence of drugs, alcohol, narcotics or similar drugs or agents;
Assuming that the insured person is addicted to drug use and has clinical symptoms such as frequent urination, urgency to urinate, Dysuria (painful urination), Hematuria, urinary hesitancy, and urge incontinence due to the use of the drug known as Ketamine (or “K powdered milk”), and seeks medical treatment for these symptoms, the medical expenses will not be reimbursed.
If the insured person undergoes breast augmentation, nose job, or other surgeries for beauty purposes, the expenses will not be reimbursed. However, if the surgery is for breast reconstruction due to breast cancer, or is a result of an accident and performed under the guidance of a doctor, it will be covered.
Many Hong Kong people have problems with myopia, astigmatism, and presbyopia, which are all considered “refractive errors” or “visual acuity”. All services related to vision, such as eye examination, eyeglass fitting, and even laser vision correction, are not covered.
To maintain good health and detect health problems early, some Hong Kong people undergo a physical examination once a year or every six months, regardless of whether the examination is performed in a hospital, clinic, or day center, and none of these expenses will be reimbursed.
Dentists recommend having teeth cleaned at least once a year, and services such as tooth filling, teeth whitening, and teeth straightening are also not covered.
For example, if a person undergoes sterilization surgery because they do not want to have children after marriage, they will not be reimbursed.
People with myopia need glasses; Those with mobility problems may need a wheelchair, and those with lung disease may need a continuous positive airway pressure (CPAP).
However, the purchase of different types of medical equipment and instruments due to illness will not be reimbursed.
Medical equipment and appliances not included in coverage are but not limited to – wheelchairs, beds and furniture, CPAP, portable oxygen and oxygen therapy equipment, blood dialysis machines, exercise equipment, glasses, hearing aids, special braces, auxiliary walking aids, non-prescription drugs, air purifiers or air conditioning and heating equipment for home use.
However, the rental of medical equipment and instruments during hospitalization or on day case procedure is covered.
Sometimes, when the body has been unwell for a long time, people want to visit a traditional Chinese medicine practitioner for treatment.
Traditional Chinese medicine treatments are very extensive, including herbal medicine, trauma therapy, acupuncture, acupressure, and massage.
There are also many alternative therapies available, such as hypnotherapy, qigong, massage, and aromatherapy. However, all traditional Chinese medicine treatments are not covered.
If you have had a family member or friend who has had cancer, you may have heard of them being invited to participate in experimental treatments at a hospital/university. Although experimental treatments are generally free, if there are any expenses involved, they will not be covered.
This refers to any medical, physical, or mental abnormality that existed at birth or before, whether or not it was diagnosed or known at the time of birth, or any abnormality that appears in newborn infants within 6 months of birth.
If you are covered by both a medical insurance plan (Product A from Insurance Company A) provided by your company and a VHIS (Product B from Insurance Company B) you have purchased yourself.
When you file a claim to one of the insurance companies and receive full reimbursement, the other company will not provide reimbursement for the same medical expenses.
In times of war, there may be artillery fire or a chance of being injured by it, losing limbs or being injured, but VHIS does not cover the cost of treatment incurred due to war.
Exclusions of General medical Insurance
When comparing VHIS with other medical insurance, VHIS has fewer exclusions. The following are some general exclusions of some medical insurance plans on the market:
- Congenital diseases
- Pre-existing conditions before/unknown at the time of application
- Day Case Procedure surgery, including endoscopy
- Inpatient psychiatric treatment
Are the exclusions of all VHIS the same?
If a customer has been diagnosed with certain diseases or has other health risk factors, such as smoking habits, family medical history, or occupational disease risk, the insurance company can add additional exclusions for individual illnesses.
When the insurance company adds additional exclusions, it must revise the “Standard Terms and Conditions” and/or “Standard Coverage Table”, or add supplementary documents, and clearly define the rights and obligations of the policyholder/the insured person /insurance company.
Will the definitions of exclusions be different for different plans?
As the Health Bureau has set standards for certified policy templates, the definitions of general exclusions are the same.
However, as mentioned above, insurance companies can add additional exclusions for different customers’ situations and revise policy documents, so the definitions of the extra exclusions may be different.
Bowtie offers a variety of VHIS, and the definitions of exclusions for each plan are the same, but the coverage provided is different. Bowtie Pink is a full-covered medical plan which charges only HK$2571 monthly!
Can adding a loading to eliminate additional exclusions?
As mentioned at the beginning of the article, insurance companies add “exclusions” to balance risk, and “adding a loading” is another measure that can “replace” exclusions and effectively balance risk.
“Loading” is referring to an additional premium to restore coverage for the original exclusions.
Once the policy becomes effective, if the policyholder does not have any conditions/diseases related to the exclusion, they can appeal to remove the loading. Of course, the measures mentioned above may not apply to all insurance companies, plans, or exclusions.
The Health Bureau also does not impose significant restrictions on loadings for VHIS, and the decision to add loadings is left to the discretion of the insurance company.
- *unless such procedure or service is recommended by a Registered Medical Practitioner, or cannot be effectively performed in a day case setting
- #except cases where HIV and its related disability is caused by sexual assault, medical assistance, organ transplant, blood transfusions or blood donation, or infection at birth
- ^unless necessitated by injury caused by an Accident and the Insured Person receives the Medical Services within 90 days of the Accident
- (1)The Bowtie Pink Voluntary Health Insurance series fully covers eligible medical expenses such as diagnosis, hospitalisation, surgery, and prescribed non-surgical cancer treatments (except in the United States), and is subject to annual benefit limits and lifetime benefit limits. If the claim involves confinement in a Mainland China Hospital unlisted in / a High-end Mainland China Hospital listed in the "List of Designated Hospitals in Mainland China" / confinement in a room higher than the restricted ward class / a pre-existing condition, the relevant benefit payable may be adjusted.