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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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