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香港很多市民都有購買保險，其中一種較多人購買的，就是醫療保險。這一節「長者法網智多聲」，就為大家說一下醫療保險。
簡單來說，醫療保險的保單，是投保人和保險公司訂立的書面合約，投保人因為患病或意外而要付醫療費的話，醫療保險就可以分擔這些開支。不過，並非所有醫療服務和開支，醫療保險都會承包的，保單一般都會列明受保範圍和不保事項，亦設有賠償上限，每項受保的事，只會賠償至某一個限額，通常保單都有列明，所以投保人最重要是在購買保險之前，小心看清楚保單的細則。
保險合約是建基於信任，保險公司相信保單持有人，投單時會如實提供準確的資料，讓保險公司可以合理和全面地評估風險，這叫「至誠原則」。如果投保人沒有披露重要事實，影響了保險公司的評估，將來保險公司可以撤銷保單或拒絕賠償。值得留意的是，大部分涉及沒有披露事實的糾紛，都和投保人的病歷有關。而其他資料，例如投保人以往的索償紀錄、平均離港時間、吸煙和飲酒習慣、甚至是交通違規紀錄和職業，即使跟投保人當時所患的病症一點關係也沒有，但有可能影響保險公司釐訂保費和評估風險、而又沒有交代的話，保險公司也有權拒絕賠償。如果您不肯定哪些資料重要，就最好全部都交代清楚了。
買了保險之後，萬一索償被拒絕，可以怎樣做呢？首先，您要了解保險公司為甚麼拒絕賠償。看清楚所有文件，如果發現是醫療帳單出錯，就要請醫生更正，如果保險公司不肯賠償某些療程的開支，就要請醫生寫一封信，證明您接受的療程是必須的。您可以寫信給保險公司，反對它不肯賠償的決定，信內要寫清楚您的姓名、個人資料、為何被拒絕賠償、您認為為甚麼應該獲得賠償等。很多保險公司在拒絕賠償之後，都容許客人在特定時間之內提出反對，所以您要把握時間，保險公司的人找您，最好就立刻回覆了。如果解決不了，您亦可以考慮向獨立的保險索償投訴委員會投訴，甚至是訴諸仲裁或訴訟。如果有任何疑問，可以問問律師。
我們在長者社區法網文字版，列出了一些購買醫療保險要注意的事，大家可以慢慢看，另外，我們也有為大家說一下人壽保險，歡迎各位到長者社區法網了解。拜拜。
PrintQuestions and answers
1. The insurance company appointed a doctor for my medical check-up before approving my insurance application. The doctor failed to discover a health problem that I did not disclose in my application form. Can the insurance company deny my claims based on the non-disclosure principle if subsequently I make such claims under the insurance policy?
Under the principle of “Utmost Good Faith”, the insured person or the policyholder has the duty to disclose all the information relating to the purchase of insurance to the insurance company.
Consequently, irrespective of there having been a medical examination conducted by a doctor appointed by the insurance company who failed to diagnose the health problem, the insurance company may still deny your claim. This is particularly so if your non-disclosure is material and affected the insurance company’s assessment of your risk profile.
2. Will medical reports issued by traditional Chinese medical practitioners be accepted by an insurance company when processing my claims?
There is usually a standard provision in an insurance policy that medical reports should be issued by a registered medical practitioner of Western medicine.
Thus, unless the policy specifically admits medical reports issued by registered Chinese medical practitioners, such reports may not be accepted for the purpose of claims.
You should check the provisions relating to claim procedures under the policy.
3. I took out an insurance policy in Hong Kong, but I was injured in a foreign country. Will this affect my claim?
That would depend on the territorial coverage of your insurance policy. If the coverage includes events that happen in a foreign country, then your claim may be admitted, subject to the terms and conditions of the policy.
4. I have taken out several insurance policies covering the same risk (e.g. hospital confinement or household damage). Can I claim the sum insured under ALL policies or just the actual expenses/losses only?
An insured person is not prevented by law from purchasing any number of insurance policies covering the same item/person for the same risk.
However, there is normally an “other insurance” clause in the insurance policy that requires disclosure by the insured person of all the other insurance taken out. The “other insurance” must cover the same risk, the insurance coverage is additional, and the relevant policies are valid and subsisting.
Typically, the clause may set out the liability of the insurance company in the situation where the insured person has also purchased “other insurance” that cover the same risks, which can be categorised as follows :
- The “escape” provision, whereby the insurance company has no liability on the insured item/person if the insured person has purchased “other insurance” which covers the same risks;
- The “excess” provision, whereby the insurance company is liable for the amount of the excess insurance over and above the “other insurance” only; and
- The “pro-rata” provision, whereby the insurance company’s liability is limited to a proportion of the loss.
These provisions apply to medical, personal injury and property insurance.
The provisions above are intended to prevent the insured person from unfair enrichment. In another words, the total amount of the claims payable under the “primary insurance”, together with the “other insurance”, should not exceed the fair value of the repair or replacement of the insured item (i.e. the total loss or all the expenses incurred).
Accordingly, you may make a claim under all of the policies. Depending on the terms of all your policies, your claims may be adjusted according to the express provisions under the “other insurance” clause, whereby the total payment will not exceed fair compensation for your loss.
Example: You have taken out two medical insurance policies in which the sum insured for medical expenses is $10,000 for each policy (i.e. an aggregate insured sum of $20,000). If your medical bill is $15,000, you will receive $10,000 from one of the policies and $5,000 from the other.