Supplementary Major Medical (SMM)
“Supplementary Major Medical” (SMM) refers to the compensation for the remaining medical expenses (when it exceeds the benefit limit of eligible benefit items.
Most medical insurance policies that include SMM on the market will reimburse 80% of medical expenses that exceed the benefit limit, with annual benefit limits ranging from HK$100,000 to HK$220,000 depending on the policy. However, the benefit table varies depending on the policy. It is worth noting that SMM also has a co-insurance, generally 20%, which means the insured person needs to pay 20% of the excess amount.
Why Do You Need Supplementary Major Medical (SMM)?
Due to medical inflation, medical expenses rise continuously and may exceed the benefit limit at any time. At this point, SMM can play its role, compensating for medical expenses that exceed the benefit limit, and significantly reducing the financial pressure on the policyholder or the insured person.
For example, suppose Mr. Chan is ill and needs to be hospitalized for multiple tests.
The total miscellaneous expense of hospitalization is HK$30,000.
However, the benefit limit for “miscellaneous expenses” in his medical insurance is HK$18,000, leaving HK$12,000 unreimbursed. In this case, if there is a SMM of HK$100,000 in the policy (with 20% of co-insurance), he can receive a total reimbursement of HK$27,600, and Mr. Chan only needs to pay HK$2,400.
| How SMM helps? | |
| Actual medical expenses | HK$30,000 |
| Reimbursement amount of “miscellaneous expenses” | HK$18,000 |
| Remaining unreimbursed amount | HK$30,000 – HK$18,000 = HK$12,000 |
| SMM reimbursement amount | HK$12,000 X 80% = $9,600 |
| Total reimbursement amount | HK$18,000 + HK$9,600 = HK$27,600 |
| Co-insurance | HK$12,000 X 20% = HK$2,400 |
What Does Supplementary Major Medical (SMM) Cover?
Using the Bowtie VHIS Flexi Regular or Plus as an example, SMM reimburses 80% of medical expenses that exceed the benefit limit for the relevant benefit items (adjusted according to the ward level). The benefit items and annual limits are as follows:
| Bowtie VHIS | ||
| Flexi Regular | Flexi Plus | |
| Reimbursement limit per year | HK$120,000 | HK$220,000 |
| Coverage items |
| |
- Note: The relevant benefit limit for intensive care is limited by the number of days, not the daily benefit limit.
- 1The 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.
How Much Can SMM Save You?
Using “Colectomy (Laparoscopic)” for Colorectal Cancer as an example, the 50th percentile charge at the St. Teresa’s Hospital in 2022 was HK$172,953, including HK$95,000 for “doctor fees” and HK$77,953 for “hospital fees,” and the patient needed to be hospitalized for 7.1 days.
If the medical insurance plan includes SMM, the expected reimbursement ratio can be increased from 74.5% to 94.9%.
| St. Teresa Hospital | Bowtie VHIS Flexi Regular – Benefit Limit | |
| Surgeon’s fee | HK$95,000 | HK$60,000（Note 1）+ HK$21,000（Note 1）+ HK$960 X 7.1= HK$87,816# |
| Anesthesiologist’s fee | ||
| Attending doctor’s visit fee | ||
| Room and board# | HK$750 X 7.1 = $5,325 | Full coverage（HK$5,325） |
| Operating theatre charges | HK$10,870 | Full coverage（HK$10,870） |
| Abdominal MRI (Plain + Contrast) | HK$9,900 | HK$6,930（Note 2） |
| Miscellaneous Charges (Note 3) | HK$51,858 | HK$18,000 |
| Supplementary Major Medical (SMM) | (HK$7,184+2,970+33,858）* X 80% = HK$35,209.6 | |
| Total surgical fee | HK$172,953 | |
| Estimated reimbursement amount/self-payment (without SMM) | HK$128,941 / $44,012 | |
| Estimated reimbursement amount/self-payment (with SMM) | HK$164,150.62 / HK$8,802.4 | |
| Reimbursement Ratio | 74.5% => 94.9% |
- #Stay in a 3-4 people standard room for 7.1 days
- Note 1: Assuming that VHIS benefits limit for “surgeon's fee” and “Operating theatre charges” can be used up.
- Note 2: If there is a 30% co-insurance, 70% of the cost will be reimbursed.
- Note 3: Assuming that the miscellaneous expenses = hospitalization expenses - Room and board - Operating theatre charges - Abdominal MRI fee
- *The miscellaneous expenses will exceed the benefit limit by HK$33,858 = HK$51,858 - HK$18,000// Surgeon fee and Anesthesiologist’s fee will exceed the benefit limit by HK$7,184 = HK$95,000 - HK$87,816
In summary, SMM can make your insurance coverage more comprehensive!
