Healthcare Insurance

Claim case sharing

Definition of Cosmetic or Plastic Surgery

Cosmetic or plastic surgery is common in Hong Kong. However, they are usually excluded by most medical insurance policies. In this issue, we will share a case from the Insurance Claims Complaints Bureau (ICCB).

The insured attended a hospital due to significant weight loss resulting in excess soft tissue and striae. He stayed in hospital for three days and received an operation to remove the excess soft tissue and striae.

When the insured was discharged from hospital, he submitted his hospital income benefit claim to his medical insurance company, but it was rejected. Why did the insured's medical insurance company reject his claim?

Although the insured's attending doctor confirmed that the surgery that he had received was not cosmetic-related surgery, the insured's medical insurance company believed that his condition was not an illness and the surgical treatment was not necessary and was for cosmetic purposes only. As such, the insured's medical insurance company, based on the exclusion of his medical insurance policy which excludes any illness, injury, hospitalisation, surgery or charges caused directly or indirectly by cosmetic or plastic surgery or any elective surgery, rejected the insured's hospital income benefit claim.

The insured filed his case with the ICCB. After investigation, the Complaints Panel was of the view that the surgical operation received by the insured was only cosmetic or elective surgery that falls within the policy exclusion. ICCB agreed with the insurer to decline the claim.

As cosmetic or plastic surgery is usually not related to injury or illness nor medically necessary, most medical insurance plans in Hong Kong have an exclusion that excludes coverage for cosmetic or plastic surgery. Therefore, customers are advised to inform their insurance agents, brokers or their medical insurance companies before receiving any non-emergency operation so they fully understand the policy details and therefore avoid any argument.

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