Does VHIS cover eye surgery? Coverage, exclusions and claim tips

Not all eye surgery costs are covered by voluntary health insurance.

Whether eye surgery costs are covered depends on the nature of the surgery. Only eye surgeries that are medically necessary (Medically Necessary), whether day procedures or inpatient surgeries, fall under the coverage of voluntary health insurance.

Voluntary health insurance lists the covered eye surgeries along with their complexity levels, allowing insured persons to clearly understand the coverage limits for different eye surgeries:

Eye Surgeries Covered by Voluntary Health Insurance and Their Complexity Levels

In fact, surgeries for correcting vision or refractive errors, as well as those for cosmetic or plastic purposes, are not covered under voluntary health insurance , as these services do not meet medical necessity criteria. Common vision correction and eye cosmetic surgeries available in the market include:

• SMILE Laser Vision Correction Surgery
• LASIK Laser Vision Correction Surgery
• Double Eyelid Surgery
• Eye Bag Removal Surgery
• Epicanthoplasty
• Lateral Canthoplasty
• Surgery for Sagging Eyelids

Of course, for certain surgeries, we cannot make a blanket decision based solely on the procedure; ultimately, it depends on whether the surgery meets medical necessity.

For example, the surgery for sagging eyelids could be for cosmetic reasons (not covered), or it could be to address symptoms like sensitivity to light, tearing, blurred vision, or inverted eyelashes. In this case, only the latter would potentially be covered under voluntary health insurance.

Example 1: A student undergoes vision correction surgery for sports convenience

Chris is a second-year university student and a member of the basketball team. He spends most of his time outside of classes and sleep practicing and competing. Chris feels his performance as a player is stable, but he’s dissatisfied with his nearsightedness, as he needs to wear contact lenses during games, and he dislikes the discomfort of wearing them and worries they might dislodge. So, on a friend’s recommendation, he visited a local eye center for the popular SMILE Laser Vision Correction Surgery.

After the surgery, Chris had to pay around HK$30,000. Later, he remembered he has a Bowtie VHIS Flexi Plan policy and heard that voluntary health insurance covers eye surgery, so he boldly attempted to claim compensation for the vision correction surgery.

Compensation situation:

• Vision correction surgery costs: ❌ Denied
• Reason: The insurance company stated that Chris’s vision correction surgery is an excluded item under voluntary health insurance, as it does not meet the criteria for medical necessity, and therefore, according to the policy terms, no compensation will be provided.

Example 2: An elderly person experiences blurred vision and undergoes cataract surgery

Donna is a retired teacher who has been retired for nearly 15 years. She recalls that she used to have excellent eyesight even when working late into the night, but in recent years, her vision has gradually deteriorated, especially in her right eye, where the field of vision has become increasingly blurry, affecting her daily life. Therefore, Donna decided to visit the ophthalmology outpatient department at a private hospital to see a specialist.

After diagnosis and assessment, the doctor confirmed that Donna has cataracts in her right eye and recommended surgery to implant an artificial lens to improve her vision. The doctor advised her to schedule the surgery soon, and Donna agreed to have it done by this doctor at the hospital. Two weeks after the consultation, Donna underwent a minimally invasive phacoemulsification day surgery at the hospital, costing about HK$20,000, and she also needed follow-up visits.

About a week after the surgery, Donna’s vision had noticeably improved. She holds a Bowtie VHIS Flexi Plan policy and plans to claim compensation from the insurance company for the cataract surgery and related outpatient/follow-up costs.

Compensation Situations:

• Outpatient Fees: ✅ Covered (up to 1 pre-surgery visit)
• Ultrasound Emulsification Minimally Invasive Surgery (Day Surgery): ✅ Covered
• Post-surgery Follow-up Outpatient Fees: ✅ Covered (up to 3 post-surgery visits)

1. Understand the Nature of the Surgery

As mentioned above, only medically necessary surgeries are covered under voluntary health insurance. However, there are many eye-related surgeries available, including those for medical needs (such as cataract and glaucoma surgeries), as well as laser vision correction (like SMILE and LASIK) and cosmetic procedures (like double eyelid surgery and eye bag removal). Many large eye centers also offer both medical and non-medical services. Therefore, if you want your surgery costs to be covered by voluntary health insurance, you must understand the nature of the services you’re selecting. If you’re unsure, it’s advisable to inquire with your insurance company before proceeding with the service.

2. Note the Coverage Limits (e.g., Doctor Fees)

Unless you have a high-end voluntary health insurance policy with no individual item limits, standard plans and general flexible plans will have coverage limits for specific medical items, such as surgeon fees, room and board, and miscellaneous expenses. You must check if the policy’s coverage is sufficient for your eye surgery. If the eye surgery costs are listed as a package price, you should clarify the services included in the package with the eye center or clinic and inquire about the claims process with your insurance company before the surgery.

3. Pay Attention to Claim Limits (Hospitalization/Surgery Pre-Visits)

Although eye surgery generally requires a short time, multiple follow-up visits are often needed before and after to monitor vision. Note that voluntary health insurance sets limits on the number of claims for related outpatient visits for hospitalization or day surgery; for example, the Voluntary Health Insurance “Standard Plan” only covers a total of 4 visits (“one before and three after,” with a claim limit of $580 per visit and $3,000 annually). Therefore, if your eye condition requires more pre-surgery assessments or post-surgery follow-ups, voluntary health insurance may not fully cover the outpatient fees.

4. Note the Required Documents

To apply for claims related to eye surgery, in addition to receipts, remember to submit the claim form completed by the registered doctor (which must clearly show the diagnosis), referral letter, imaging diagnostic reports, and other medical reports to the insurance company to avoid your claim being rejected due to insufficient documentation.

First, everyone needs to understand that medical insurance and critical illness insurance serve different purposes:

• Medical insurance: In the form of actual reimbursement , it provides compensation for eligible medical expenses
• Critical illness insurance: In the event that the insured unfortunately suffers from a specified serious illness, it provides compensation in the form of a lump sum to cover the insured’s living expenses during the period of illness-related absence from work, allowing the insured to focus on treatment and recovery

Therefore, if you unfortunately suffer from a critical illness, having only medical insurance may cover your medical expenses but might not address the long-term issues you face due to the illness. In fact, when you are diagnosed with a critical illness, even if it is not life-threatening, it often forces you to stop working and lose income, which can affect your quality of life and disrupt your existing plans.

Since medical insurance and critical illness insurance provide complementary coverage, a reliable critical illness insurance policy can replace the income you lose while out of work, providing financial support and reducing the impact on your family, thereby maintaining your original quality of life.

Moreover, even if you cannot purchase new insurance after falling ill, the critical illness compensation can help you continue paying for your existing medical insurance premiums when necessary.

Critical illness insurance is absolutely an essential form of protection. Beyond medical insurance, the importance of critical illness insurance cannot be overlooked. In any situation, as long as you have a stable income, you should actively consider purchasing a critical illness policy to provide an extra layer of protection.