How to claim medical insurance?


How to claim medical insurance?

No one wants to fail their insurance claims after medical check-ups and treatments. However, not everyone is familiar with the claim procedures. Missing documents or other mistakes throughout the claim process may lead to unsuccessful claims. Bowtie will share more about claims in the article below.

We all understand the importance of medical insurance, while some of us may already have more than one policy on hand. However, not everyone is familiar with the details of their own insurance plan.

What should you do to file a claim, and which part should you pay attention to? What documents are required in the process? What is Supplementary Major Medical (SMM)? The following case study can help us understand these aspects better:

Real Claim Case*

One Sunday morning, Lydia got a call from her family,that her father had a sudden chest pain and breathing difficulties the night before. Although his condition had improved slightly in the morning, Lydia was still very worried. She would like to take his father to hospital for a body check, just did not know whether they should go to a public hospital or a private hospital.

Given that Lydia’s father had medical insurance, to speed up the whole check-up and avoid sudden deterioration, she chose to contact a cardiologist and arranged detailed examinations for her father at a private hospital on the same day.

After conducting various examinations, including different checks like exercise electrocardiogram and computer scans (CT), the doctor confirmed that Lydia’s father had a severe blockage in one of his coronary arteries and needed to conduct coronary angioplasty(also known as balloon angioplasty). 

So Lydia’s father has the surgery done the next day. Fortunately, they discovered this early,thus, settled all examinations and surgery quickly. After resting for a few days, Lydia’s father was discharged from the hospital. The hospitalization and surgery costs, including other miscellaneous expenses, were approximately HK$150,000 for a four-day stay.

  • *for reference only

Three Essential Documents for Claiming Insurance

The next step was to file an insurance claim. Before discharge, it is necessary to prepare the following three documents for future claims:

  • Medical claim form completed and signed by the doctor
  • Original hospital receipt
  • All pathology reports

Private hospitals usually have different medical claim forms for different insurance companies. As long as you inform the doctor of the medical insurance policy you have in hand, they could fill out the form for you. It is recommended to prepare a list of benefit items and limit of your medical insurance so the doctor can take it as reference.

Back to Lydia’s case, the approval process is completed in about a week after submitting the documents, and Lydia received a reimbursement of HK$120,000. Some of you may be curious, why isn’t the insurance plan giving a full cover of HK$150,000? How was the amount of HK$120,000 calculated?

The Role of Supplementary Major Medical Insurance (SMM)

Continuing with the example of Lydia, the table below shows the fees charged by the hospital and doctor, as well as the compensation details from the insurance company. 

Fees such as Attending doctor’s visit fee, hospital miscellaneous expenses, surgery fees, and operating room fees all exceed the limit of basic coverage of the insurance Lydia’s father holds. 

Hospital miscellaneous expenses usually include various tests such as blood tests, Cardiac Ultrasound, Exercise Electrocardiogram, and Computed Tomography (CT) scan , which often easily exceed the limit of basic coverage. 

Fortunately, this medical insurance includes Supplementary Major Medical (SMM) coverage, which covers 80% of the excess costs.

CoverageActual expensesReimbursement amountDifference
Basic Coverage
Ward and mealsHK$3,798HK$3,798HK$0
Attending doctor’s visit feeHK$8,000HK$3,432HK$4,568
Hospital miscellaneous expensesHK$20,694HK$9,750HK$10,944
Surgical feesHK$70,000HK$29,250HK$40,750
Operating room chargesHK$41,835HK$11,700HK$30,135
Pre- and post-Confinement/Day Case Procedure outpatient careHK$4,050HK$975HK$3,075
Extra medical coverage (more than 80% of basic coverage)
(= HK$84,904 x 80%)
[b] HK$67,923
Total amount of Reimbursement
(= [a] + [b])

Sharp-eyed readers may notice that the operating room fee in this case is higher than usual, and the SMM does not include the difference in operating room fees. This is because the cost of this case was allocated to the attending doctor’s visit fee, and the SMM only includes the attending doctor’s visit fee from day 181 of hospitalization onwards.

Different insurance companies may have different approaches.

In summary, a comprehensive medical insurance plan is essential, and SMM is particularly important. 

Only with medical insurance can you choose to receive medical treatment at a private hospital without money concern

If you have a choice, you are the boss.

Using this case as an example, if there was no SMM, the out-of -pocket expenses would not be just HK$20,000 but nearly HK$90,000. 

If you think that the basic medical insurance coverage you have now is not sufficient, consider upgrading the plan with a higher level of coverage!

The 6 Common Questions About Insurance Claims

1. Can non-hospitalized surgeries be claimed under insurance?

🤔 I need to have a small surgery done, and the doctor recommends doing it in an outpatient setting. However, I only have hospitalization insurance. Can non-hospitalized surgeries be also claimed under insurance?

😎 The “surgeon fee” of VHIS covers the cost of surgery performed during hospitalization or in a day case procedure center for the insured person.

As long as the situation meets the policy conditions, even if the surgery is performed in an outpatient or day case procedure center, it can be covered.

2. Can I not claim if I didn't notify the insurance company in advance?

🤔 I was hospitalized due to an emergency health situation, and only notified the insurance company afterwards. What’s more, I didn’t estimate the reimbursement. Can medical expenses not be claimed?

😎 In fact, it is not necessary to inform the insurance company before hospitalization, but it is best to understand what documents are required for claims before being admitted.

In this way, when you are discharged, you can immediately check whether the documents issued by the doctor/hospital are sufficient to claim reimbursement.

If there are omissions, you can ask the doctor/hospital to provide them immediately.

3. Is it necessary for a doctor to fill out a claim form?

🤔 I didn’t ask the doctor to fill out a claim form. Can insurance not be claimed?

😎 The claims department of the insurance company will review the claim application form filled out by the doctor and the documents issued by the hospital to approve the claim.

If documents are missing, the customer may need to submit supplementary documents, or the insurance company may specifically request documents from the doctor/hospital to obtain sufficient information to approve the case.

4. Will I not be able to claim it if I am late?

🤔 I have not applied for reimbursement from the insurance company for a long time after being discharged because I need to rest and have follow-up visits. Will I not be able to claim medical expenses?

😎 Each insurance company has different deadlines for claims, usually ranging from 30 to 90 days. Some insurance companies (like Bowtie) will handle claims submitted after the application deadline according to the individual circumstances. If there is a reasonable explanation, many insurance companies will handle it at their discretion.

5. Can I make a claim if I need hospitalization while traveling out of town?

🤔 When I travel out of town, if I need urgent medical treatment and have to be hospitalized locally, can I make a claim without purchasing travel insurance and only having VHIS?

😎 VHIS provides global coverage. Therefore, even if the insured person is hospitalized overseas, they will be covered. However, when applying for a claim, it is important to note that when discharged from the hospital overseas, you should ask the doctor/hospital for medical documents (such as the claim form filled out by the doctor, the original receipt issued by the hospital, and inspection reports).

If the medical documents are incomplete, you may need to return to the local hospital after returning to Hong Kong to apply for them, or it may take longer to collect the documents before submitting the claim.

# psychiatric treatment is limited to Inpatient Hong Kong hospitals treatment only.

6. Can I make a claim for routine health check-ups?

🤔 My doctor recommends that I have a routine health check-up every year.I have VHIS, can I file a claim for the cost of the check-up?

😎 Generally, routine health check-ups are not covered by medical insurance policies(including VHIS), so the cost of the check-up will have to be paid out-of-pocket.

After reading the above examples and common questions, I believe everyone understands the scope and procedures of medical insurance claims. 

However, when health problems arise, most people would still worry about the claims, and be afraid of facing complicated claim procedures and handling related documents. Some people may have more doubts and concerns toward virtual insurers on inadequate compensation and lack of follow-up.

As a virtual insurance company, Bowtie understands everyone’s concerns and prepared several real claims cases to present our VHIS’s “reimbursement ratio” and “reimbursement amount” for your reference:

As for the claims procedure, it is very simple. All claim applications could be submitted online, and at the same time, there will be claims specialists following up on the case for customers, assisting in claim estimation, and providing progress updates.

Want to know more about Bowtie’s VHIS claims process? Visit the website

Next article - How to Claim from Two Medical Insurance Policies?
Many people in Hong Kong have more than one medical insurance policy. Can they claim from two medical insurance policies? Bowtie is here to show you how to do it!
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