What is congenital diseases definition? Can VHIS cover them?

Congenital diseases, sometimes referred to as congenital defects or congenital abnormalities, are structural or functional abnormalities that exist before or at the time of a baby’s birth, such as congenital heart disease, metabolic disorders, or hearing impairment.

Depending on the type and severity of the disease, congenital conditions can be discovered prenatally, at birth, or even days to months after birth. For example, severe congenital heart disease may show obvious symptoms before or at birth, which can even be fatal; however, congenital hearing or vision defects might only be gradually discovered as the baby grows.

Some congenital diseases or defects can be improved through surgical treatment; however, others may have long-term effects on the patient’s life, requiring ongoing treatments such as medication, physical therapy, speech therapy, and occupational therapy.

Here are some common congenital diseases:

• Congenital heart defects: Tricuspid atresia, Tetralogy of Fallot, Interrupted aortic arch, etc.
• Inborn errors of metabolism (IEM)
• Esophageal atresia / Tracheoesophageal fistula
• Intestinal atresia / Stenosis
• Anorectal atresia / Stenosis
• Renal dysplasia
• Cranial fissure
• Spina bifida
• Cleft lip and palate
• Omphalocele
• Hypospadias
• Microcephaly
• Microtia
• Clubfoot
• Iris defect
• Down syndrome

Currently, globally, about 240,000 newborns die within 28 days of birth from congenital diseases, and another 170,000 children die between 1 month and 5 years old from the same causes each year. However, nine out of ten children born with severe congenital diseases are from low- and middle-income countries. Furthermore, as the death rate for children under 5 and newborns continues to decline, the proportion of deaths due to congenital diseases in this age group is steadily increasing.

The causes of congenital diseases can be broadly divided into genetic factors and other external environmental factors, which include:

• Genetic factors: For example, chromosomal abnormalities that lead to Down syndrome; single-gene defects that cause cystic fibrosis
• Maternal age: Advanced maternal age increases the risk of chromosomal abnormalities
• Maternal malnutrition: For example, a lack of folic acid in the first three months of pregnancy can increase the risk of congenital defects in the fetus’s brain and spinal cord
• Smoking or drinking alcohol during pregnancy: These unhealthy habits can increase the risk of congenital defects in the fetus’s brain and heart
• Exposure to viral infections, medications, pollutants, or radiation: This may increase the risk of intellectual, hearing, or vision impairments, cleft lip and palate, brain, heart, and other organ diseases in the fetus
• Maternal gestational diabetes: This increases the risk of fetal malformations, respiratory difficulties, enlarged organs, and excessive fetal weight.

• Pre-pregnancy or prenatal check-ups: Women planning to conceive should undergo pre-pregnancy check-ups with their partners to assess their health status and genetic disease risks. After becoming pregnant, women should have regular prenatal check-ups and screenings recommended by obstetricians, such as fetal structural ultrasound (commonly known as structural scan), Down syndrome screening, and non-invasive fetal chromosomal screening (T21 and NIFTY)
• Good lifestyle habits: Pregnant women should maintain a balanced diet, get adequate rest, and avoid smoking and alcohol (including secondhand smoke)
• Taking supplements: Pregnant women can take supplements such as folic acid, vitamins, calcium, and DHA as recommended by their obstetricians to promote normal fetal development
• Vaccination: Pregnant women may consider getting vaccines for viruses like rubella and cytomegalovirus to prevent congenital conditions in the fetus due to infection
• Avoiding risks: Pregnant women should avoid exposure to harmful substances such as heavy metals and chemicals, and also avoid radiation; if unwell, they should consult a doctor before taking any medication

In Hong Kong, traditional medical insurance generally excludes congenital diseases, as insurance companies consider them pre-existing conditions before the policy takes effect. Traditionally, medical insurance is designed to cover medical conditions that arise after the policy starts.

Of course, this arrangement is also due to the insurance companies’ risk management and commercial considerations, as the treatment and care for congenital diseases are often long-term and involve high costs.

Case of Denial of Coverage for Congenital Diseases in Traditional Medical Insurance

According to the Insurance Complaints Bureau (ICB) 2018/19 annual report, the policyholder purchased Medical Insurance for his 11-month-old son. Five days after the policy was issued, he was hospitalized for right inguinal hernia repair surgery . After discharge, he submitted a claim to the insurance company. The insurance company denied the claim on the grounds that the disease was congenital. The policyholder then complained to the ICB.

The ICB’s Insurance Claims Complaints Committee, based on medical literature, learned that inguinal hernia is one of the most common congenital defects in children, resulting from the internal inguinal ring not closing after the testicles pass through during fetal development. Ultimately, the complaints committee agreed that the insured’s condition was congenital and supported the insurance company’s decision to deny compensation.

The above misunderstandings often lead to many unnecessary disputes involving insurance claims. Of course, a professional and responsible insurance company should be able to clearly explain these concepts and assist clients in answering health questionnaires and providing required information. However, as consumers, policyholders should also understand these concepts clearly and ask the insurance company if anything is unclear.

Voluntary Health Insurance can cover congenital diseases that appear or are diagnosed after the age of 8 (provided they were not detectable and should not have been detectable at the time of policy purchase), thereby addressing the coverage gap in traditional medical insurance.

Congenital diseases often require longer treatment and care, resulting in higher medical expenses. If you want more comprehensive medical coverage, consider opting for a high-end Voluntary Health Insurance product like Bowtie Pink that offers deductible options and full reimbursement*. Calculate your personalized premiums for different deductibles now!

First, it is important to understand that medical insurance and critical illness insurance serve different purposes:

• Medical insurance: Provides reimbursement on a claims-made basis for eligible medical expenses
• Critical illness insurance: Provides a lump-sum payment if the insured is diagnosed with a specified serious illness, to cover living expenses during the period of absence from work, allowing the insured to focus on treatment and recovery

Therefore, if you are unfortunately diagnosed with a critical illness, having only medical insurance may cover your medical costs but not the long-term challenges you face. In reality, a critical illness diagnosis, even if not fatal, 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 policy can replace lost income during your absence from work, providing financial support and reducing the impact on your family, while maintaining your original quality of life.

Even if you can’t buy new insurance after getting sick, critical illness compensation can help you continue paying for your existing medical insurance premiums when necessary.

Critical illness insurance is absolutely an important protection. Besides medical insurance, the importance of critical illness insurance cannot be ignored. In any situation, as long as you have a stable income, you should actively consider purchasing a critical illness insurance for yourself for an extra layer of protection.