Health Insurance Exclusions: Why and How They Impact Your Claims

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Have you already been caught with unexpected medical expenses? Sometimes, health insurance doesn’t bear the cost of certain medical services. This is generally referred to as “exclusion”, which is not covered by your coverage. All health insurance plans have common exclusions, but conditions can vary from one insurer to another. While the best-known exclusions are "pre-existing conditions", there are many other items that are not covered by health insurance products and that you should beware of: especially lesser-known exclusions that can cause outrageous medical bills.

We at Alea are providing you a 3-min read summary of these key exclusions.

Pre-existing conditions and congenital deformities or anomalies

In terms of individual health insurance, both “international” and “local Hong Kong” insurance providers discriminate against "known" pre-existing conditions. The list is long and may include conditions as diverse as asthma, eczema, diabetes, back pain, cancer history, chronic migraines, psoriasis, hypertension, and HPV. As for the compliant VHIS plans that were launched in April 2019, they are even more restrictive as they also limit coverage of "unknown" pre-existing conditions.

➜ EXPERT TIP: How to be covered for pre-existing conditions? While employee medical benefits usually cover pre-existing conditions, you generally lose such coverage when leaving your job. The best time to purchase private health insurance is when you are young and healthy. That way, you lock in coverage for life and get covered for unknown or future conditions.

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Cosmetic surgery

Medical insurance policies systematically exclude cosmetic or plastic surgery to enhance one’s appearance as these treatments are not considered medically necessary. For instance, removing the excess of soft tissue and striae after a significant weight loss is not covered by health insurance. That being said, necessary plastic surgery following an injury or accident is generally covered by medical insurance.

Check ups, dental and optical care

In Hong Kong, comprehensive health insurance plans with outpatient cover usually cover health check ups.

Nevertheless, the plans set sub-limits that can range between HK$ 500 and HK$ 2,000. For example, you may be covered for a physical exam every year up to HK$ 500 or every 3 years up to HK$ 1,000. This time limit and financial limits may vary according to the product. Make sure to check with a health insurance advisor before getting screened.

Usually, you need an optional benefit for dental and optical care. Dental care is very expensive in Hong Kong. Also, optical coverage is rarely provided by employers and local basic products due to the high rate of myopia in Hong Kong.

Childbirth and related expenses

Maternity coverage isn’t automatic and most often not covered by medical insurance. It is important to know that you cannot just buy maternity coverage. It is always bundled with "inpatient" coverage or "inpatient + outpatient" coverage. Pregnancy coverage aims at protecting women from the costs associated with childbirth, as well as prenatal and postnatal care.

Pregnancy insurance usually covers:

• Prenatal/postnatal care
• Vaginal delivery
• Medically prescribed C-section
• Elective C-section (not all plans)
• Delivery with complications
• Pain management fees (anaesthetist fees + medicine)
• In hospital paediatrician fees

Some more comprehensive plans may also include:

• Fertility treatments
• Congenital birth deficiency and special care for newborns in case of an unexpected problem
• Prenatal vitamins
• Childbirth classes
• Extra midwife services

It is also important to know that maternity insurance typically has a "waiting period" during which you cannot claim maternity-related expenses. If you become pregnant at the end of the waiting period, only maternity expenses that are incurred after the waiting period will be covered.

High-risk activities and extreme sports

High-risk activities and extreme sports are subject to exclusions. If you practice extreme sports or high-risk activities, you may have to get sport-specific insurance. According to our market research, the individual Bupa Global plans are the only ones that do not have any exclusions on sports activities.

➜ EXPERT TIP: Sports-related injuries/accidents are usually covered when:

• you do not engage in a professional matter
• the sport is not considered hazardous
• scuba diving is limited to a depth of less than 30 meters
• the winter sport was not off-piste

Substance abuse or self-inflicted injuries

Drug and substance abuse treatment is usually excluded from the list of covered benefits. If you need to be hospitalized because of substance abuse or want to go to a rehabilitation center, you have to bear the cost personally.

Also, suicide and self-inflicted injury are outside of the list of covered benefits. If the insured person has committed suicide or has injured himself in the course of attempting to commit suicide, a claim for insurance under the policy will be rejected.

Mental disorders

Mental health care was traditionally excluded from health insurance coverage in Hong Kong. Therefore most psychological and counseling treatments and services are excluded by insurance providers.

Fortunately, things are changing and more and more insurance providers are providing mental health coverage to their members. This is especially true for international and comprehensive medical insurance plans. Some of the mental coverage improvements we have witnessed in the past years include: doctor, psychiatrist, psychologist and psychotherapist consultation fees, diagnostic scans, tests, and medicines prescribed by a physician.

There are some additional and important other exclusions you should know about in regards to medical insurance plans. If you have any specific questions or concerns, you should seek advice from a health insurance advisor.

• Artificial limbs & prosthesis
• Experimental treatment (i.e. experimental cancer treatments)
• Fertility treatment (very few medical plans cover IVF)
• AIDS or HIV diseases
• Contraception, including sterilization
• Sexual dysfunction
• Obesity treatment
• Lifestyle-related conditions (as smoking or drinking alcohol)