Medical insurance

Questions 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.