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Multiple surgical procedures in one single incision

Ms. Chan was admitted for abdominal pain with an oophorectomy and appendectomy done last month. The total cost incurred for Surgeon, Anaesthetist and Operation Theatre was HK$126,000. After discharge from hospital, Ms. Chan submitted her claim for hospital expenses to her medical insurance company.

In her plan, the maximum benefit limits for Surgeon Fee, Anesthetist Fee and Operation Theatre were HK$93,000, HK$26,000 and HK$26,000 respectively. The limits should have been able to cover all of Ms. Chan's medical expenses. However, the insurance company only reimbursed HK$96,000 of Ms. Chan’s operation expenses. Why couldn't Ms. Chan have her medical expenses fully reimbursed?

According to Ms. Chan’s medical insurance policy,

“If more than one surgical procedure is performed through one single incision, reimbursement for all such procedures, including that for surgeon fee, anaesthetist fee and operation theatre charges, shall not exceed the amount payable for the surgical procedure with the highest percentage of Surgical Schedule.”

Based on the Surgical Schedule, the maximum surgical benefit for oophorectomy was 85% and that for appendectomy was 50%. Details of the Surgeon Fee, Anaesthetist Fee and Operation Theatre Fee of the surgical procedures received by Ms. Chan were as follow:

 

Appendectomy

Oophorectomy

Max
Benefit
Limit

Max
Benefit
Payable for
85%

Actual
Benefit
Payable

%/HK 50% 85%   85% 85%
Surgeon Fee 30,000 55,000 93,000 79,050 55,000
Anaesthetic
Fee
  20,000 26,200 22,270 20,000
Operation
Theatre
  21,000 26,200 22,270 21,000
Total 30,000 96,000     96,000

According to the condition stated in the policy, Ms. Chan could only be reimbursed with the cost incurred for the surgical procedure that had the higher percentage of the Surgical Schedule. Therefore in Ms. Chan’s case, the surgical procedure cost of oophorectomy of HK96,000 could be reimbursed.

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