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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。

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Practical tips for disputing a medical claim denial by an insurance company

Medical insurance

  1. To dispute a medical claim denial, you first have to understand why the medical claim was denied. Be sure to carefully review your medical bills, medical notes and medical reports, and the terms of your medical insurance policy. Your policy explains what your insurance company covers and excludes.
  2. If you see fit, you may approach the insurer concerned to lodge a complaint. You may speak to a representative about your dispute and ask for the reasons for denial. This would give the insurer concerned a chance to look into the matter with a view to resolving your complaint at an early stage.
  3. If there are any errors on your medical bills, contact your doctor for clarification and correction. If your claim is denied for another reason, ask for an explanation and the specific steps needed to appeal your claim denial.
  4. Call your doctor’s office. If your claim was denied because of an error in your information, ask the office to resubmit your claim with the correct information.
  5. Talk to your doctor. Ask your doctor about the medical necessity of your medical procedure. If your doctor feels that the procedure was necessary, he or she is likely to write a letter to your insurance company explaining why the procedure was necessary.
  6. Obtain a letter of medical necessity from your doctor. The letter of medical necessity should say why it was necessary for you to receive the denied procedure and why no other procedure would have been adequate.  Send a copy of this letter to your medical insurance insurer to support your appeal.
  7. Write a letter to your insurer disputing the claim denial. Include your name, personal particulars, reason given for the denial, reason why you or your doctor feel that the claim should be covered, and what you would like the insurance company to do. You may ask the insurance company to reconsider its decision and cover your claim. Include any supporting documents, including a letter from your doctor and/or your medical records.
  8. Act in a timely manner. Respond immediately to all correspondence from the insurance company. Many insurance companies have a time frame in which they allow you to dispute medical service denials. Pay attention to the prescribed time limitation.
  9. If you feel aggrieved by your insurer’s denial of claim or inadequate payment for your claim, your policy usually provides a procedure for arbitration as a method for settling disputes.
  10. You can file a complaint with the Insurance Complaints Bureau (“ICB”). The Insurance Claims Complaints Panel appointed by the ICB will handle the complaint by way of adjudication. The Panel’s decision is binding only on the insurer, not the claimant.
  11. If you still feel aggrieved after the Panel’s decision, you can resort to arbitration or litigation.
  12. Consult your lawyer if you are in doubt about any of the above.