Does VHIS cover outpatient services?


Does VHIS cover outpatient services?

Although VHIS is mainly for inpatient medical care, it also provides coverage for some outpatient/day case procedure center check-ups and treatments. Bowtie's team will analyze in detail which outpatient services can be claimed!

Before discussing outpatient coverage in detail, the table below provides a simple answer to the common question “Does VHIS cover outpatient services?”:

In what situations does VHIS provide outpatient coverage?
CaseMedical Cost^VHIS StandardVHIS FlexiBowtie Pink
🤒 Visiting a hospital outpatient clinic or clinic for treatment of cold or flu without hospitalization or surgery Outpatient consultation fee + medication costXXX
🔎 Visiting a clinic due to bloody stools and being referred for outpatient colonoscopyOutpatient consultation fee + medication cost + colonoscopy fee
😷 Follow-up visit to a clinic one week after undergoing a colonoscopy Follow-up consultation fee + medication cost 
🤕 Visiting a hospital outpatient clinic or emergency room for treatment of accidental injury*Outpatient consultation fee + treatment costX
🩺Receiving kidney dialysis at a clinic Dialysis costX
👨‍⚕️Being referred by a doctor for diagnostic imaging at a clinic (e.g. CT, MRI, etc.) Imaging cost#
  • *Does not include general practitioner’s clinics
  • ^Other medical expenses may be involved in each scenario and are for reference only
  • #30% co-insurance applies

How are "outpatient" treatments/check-ups defined?

Patients receive treatment through two main channels: inpatient and outpatient treatment.

  • Patients receiving inpatient treatment need to be admitted to the hospital and undergo relevant tests, even surgery, during which they can receive comprehensive care from medical staff.
  • As for outpatient treatment, patients can choose to seek medical treatment at the hospital outpatient department/emergency department or private clinics. Clinics generally have established service hours, and patients may need to make appointments to receive diagnoses and treatment from doctors.

Currently, outpatient services in Hong Kong can be roughly divided into three categories:

  1. Private clinics (family doctors and specialist doctors, etc.)
  2. General practitioner clinics, specialist clinics, and emergency clinics under public hospitals
  3. General outpatient clinics and specialist clinics under private hospitals

If a patient experiences general discomfort, such as a cold or diarrhea, they generally go to a private clinic or the general outpatient clinic of a hospital for treatment. If the doctor determines that the patient’s condition requires further testing and treatment, they will make a referral to a specialist doctor or directly refer the patient to the hospital for admission. If an accident occurs or the symptoms are severe, the patient can go to the emergency department for treatment.

So, which outpatient services are covered by voluntary health insurance?

Pre- and post-confinement / Day case procedure outpatient care

One of the outpatient-related benefit items included in the VHIS recognized by the Health Bureau is “Pre- and post-confinement / Day case procedure outpatient care“. This benefit item applies to outpatient or emergency fees required before hospitalization or day surgery, as well as follow-up outpatient fees provided by the attending doctor after discharge or day surgery, or as recommended in writing.

Under the VHIS Standard plans, this benefit item has a limit on the number of claims and the benefit limit. For example, there can be up to one or two outpatient or emergency visits before hospitalization or day surgery, and up to three follow-up outpatient visits within 90 days after discharge or day surgery, with a maximum benefit limit of HK$580 per visit and a maximum annual benefit limit of HK$3,000 per policy. The benefit limits vary depending on the plan, and for example, Bowtie’s plan has its own benefit limits.

CaseVHIS StandardVHIS FlexiBowtie Pink
Outpatient Coverage1 time before; 3 times after 12 times before; 3 times after 2
Benefit Limit/ timeHK$580HK$900 / 1,300Full Coverage 3
Annual Benefit LimitHK$3,000HK$3,000 / 6,400NIL
  • 1Coverage for up to one outpatient or emergency visit before hospitalization or day surgery, and up to three follow-up outpatient visits within 90 days after discharge or day surgery.
  • 2Coverage for up to two outpatient or emergency visits before hospitalization or day surgery, and up to three follow-up outpatient visits within 90 days after discharge or day surgery.
  • 3Bowtie Pink Voluntary Health Insurance series provides full reimbursement for qualified medical expenses, including diagnosis, hospitalization, surgery, and specified non-surgical cancer treatment, subject to annual and lifetime coverage limits. Compensation amounts may be adjusted if the claim involves hospitals in Mainland China outside the designated hospital list, high-end hospitals within the designated hospital list in Mainland China, exceeds the designated ward level, or pre-existing conditions at the time of application.

Accident emergency outpatient treatments

Many insurance companies’ Flexi Plans offer coverage for emergency outpatient treatment for accidents. When the insured seeks medical treatment at a hospital due to an accident, outpatient medical expenses can be reimbursed.

Example: The insured suffered a left-hand injury due to an accident and needed to go to the hospital emergency room for stitching and X-ray examination, and the expenses can be claimed under this benefit item.

VHIS StandardVHIS FlexiBowtie Pink
Scope of ProtectionEmergency outpatient treatment expenses arising from accidental injury.
Annual Benefit LimitXHK$8,000Full Coverage 3

Bowtie Flexi Plans provide HK$8,000 per policy year for emergency outpatient care for accidents, which is sufficient according to the actuarial team’s analysis of tens of thousands of claims data over five years. Only less than 0.1% of insured persons claimed more than once for emergency outpatient treatment within one year. 

Based on two claims for emergency outpatient visits, Bowtie estimated that the cost of each emergency treatment is about HK$3,000 to HK$4,000, so HK$8,000 is sufficient to cover most people.

Of course, if you need more coverage, you can also consider purchasing Bowtie Pink (high-end health insurance), which provides full reimbursement for qualified expenses.

Outpatient kidney dialysis

Acute renal failure is common in elderly patients, so many Flexi VHIS plans on the market also provide coverage for outpatient kidney dialysis, and Bowtie VHIS Flexi is one of them. The benefit limits are as follows:

VHIS StandardVHIS FlexiBowtie Pink
Scope of ProtectionOutpatient kidney dialysis
Annual Benefit LimitXHK$50k / HK$100kFull Coverage 3

Currently, kidney dialysis services on the market charge between HK$1,250 and HK$2,300 per session#. Assuming the cost of each dialysis session is HK$2,300, the annual benefit limit of HK$50,000 under the Bowtie VHIS Flexi Plan can cover the cost of three sessions per week for seven weeks.

Bowtie Pink even provides full reimbursement for kidney dialysis expenses.

  • #The fee information is sourced from the websites of the Yan Chai Hospital Charitable Dialysis Centre, Tung Wah Group of Hospitals Renal Centre, and Union Hospital Nephrology and Dialysis Centre, published on September 3, 2020.

Outpatient diagnostic imaging (such as CT/MRI)

CT scans, MRIs, and other diagnostic imaging tests are commonly used to diagnose various medical conditions. In simple cases, these tests can be conducted in outpatient clinics or medical centers without the need for hospitalization. 

For example, if a doctor wants to check whether a patient’s finger pain is caused by soft tissue problems, an MRI scan can be done in a clinic for diagnosis.

However, traditional medical insurance usually only covers diagnostic imaging tests (such as MRIs) that are conducted during hospitalization. As a result, many insured individuals intentionally schedule hospitalization for such tests, which can be costly, time-consuming, and may even affect claims if they do not meet medical requirements. 

VHIS, on the other hand, does not have such limitations, and insured individuals can be covered even if they undergo diagnostic imaging tests (such as CT, MRI, and PET scans) in medical centers or outpatient clinics.

The benefit limits are as follows:

VHIS StandardVHIS FlexiBowtie Pink
Scope of ProtectionPrescribed diagnostic imaging tests4
Annual Benefit LimitHK$20k 5HK$26k / HK$40k  5Full Coverage 3
  • 4 The Company shall have the right to ask for proof of recommendation e.g. written referral or testifying statement on the claim form by the attending doctor or Registered Medical Practitioner.
  • 5Set at 30% co-insurance.

Is an annual benefit limit of HK$20k to HK$40k sufficient? Take Hong Kong Gleneagles Hospital as an example:

Diagnostic imaging tests Outpatient FeeGeneral ward/ day case procedure fee
CT ScanHK$4,770 – 15,300HK$5,300 – 17,000
MRIHK$11,250 – 14,790HK$12,500 – 16,430
PET-MRHK$16,690 – 23,040HK$18,540 – 25,600
PET-CTHK$16,650 – 18,900HK$18,500 – 21,000

If we calculate based on the most expensive CT scan (i.e., chest and abdomen), the benefit limit is sufficient to cover at least one test per year.

Outpatient services do not covered by voluntary health insurance

VHIS provides coverage for hospitalization, so general outpatient services are not covered.

For example, if you experience general discomfort such as a cold or flu and need to see a family doctor or a general practitioner in an outpatient clinic, VHIS Standard and most Flexi plans on the market do not provide compensation for general outpatient medical expenses.

However, regular group health insurance usually provides coverage for general outpatient services. If you do not have company health insurance, you can consider purchasing additional outpatient coverage under VHIS.

Bowtie Outpatient Membership Plan: BowtieGo

Recognizing the demand for general outpatient services, Bowtie has created a health and wellness membership plan called BowtieGo, which offers “exclusive prices” for outpatient services within its network to VHIS customers.

BowtieGo has three levels: the free version, which is included as a bonus for Bowtie VHIS policyholders upon successful enrollment, and customers can upgrade as needed to obtain greater coverage:

Learn about the difference of each Bowtie VHIS Plans

Free 7Standard Premium
Accept outpatient services within the network at “exclusive prices” 
Death benefit (HK$3,000)

Bowtie offers various VHIS plans with different levels of coverage, from standard plans to high-end VHIS.The coverage for outpatient and hospitalization varies among different plans, so take a look and find the plan that suits you best!

Learn about the difference of each Bowtie VHIS Plans

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