Claim case sharing
Is hospital in-patient treatment covered by medical insurance?
Ms. Wong took out a health policy covering Hospital Benefit for 5 years. Recently, she experienced repeated back pain and general malaise over a period of almost 3 weeks. She consulted her doctor who recommended that she be admitted to hospital for a detailed check up. An MRI scan, X-rays, an electrocardiogram, ultrasound and a series of laboratory tests were performed during her stay in hospital. The results of most of the tests were normal except for the ultrasound, which revealed a gallbladder polyp. Ms. Wong was discharged the following day.
Ms. Wong then submitted a claim to her insurance company for the hospital expenses. Her claim was rejected for the reason that the admission was not “medically necessary”. Ms. Wong called her insurance company and asked: “My admission to the hospital was recommended by my attending doctor, so why have you rejected my claim?”
Although the series of tests might have been medically necessary to discover the underlying diagnosis for the insured’s condition, all of them could have been effectively performed on an outpatient basis. As the admission was not due to an emergent condition and the series of diagnostic tests performed could have been carried out on an outpatient basis, Ms. Wong’s hospitalisation was considered not “medically necessary” under the Hospital Benefits section of her policy.
Most hospital insurance policies, including MSIG’s MediSure Plus and Hospital Care Insurance, do not cover unnecessary hospitalisation. This is excluded under General Exclusions:
“Hospital in-patient treatment for conditions which can be properly treated as an outpatient. This includes hospitalisation primarily for diagnostic scanning, X-ray examinations or physiotherapy treatment.”
To avoid any misunderstanding, customers are advised to call the 24 hrs emergency assistance hotline for advice when referred for hospitalisation by their attending doctor.