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Common Complaints About Claims

Many complaints about insurance claims arise from the omission of health history by applicants.

The Importance of Accurate Disclosure

Insurance contracts are based on the principle of "utmost good faith," meaning that applicants must proactively disclose all "material facts," including their health status and medical history. This allows the insurer to reasonably assess risk. During the underwriting process, the insurer may make the following decisions based on the applicant's health condition:

• Accept coverage without additional premium or exclusions

• Charge an additional premium

• Add specific exclusions

• Deny coverage

According to the Insurance Authority, if an applicant violates the principle of "utmost good faith" by misrepresenting or omitting health status, the insurer can deny claims based on non-disclosure of "material facts." Even if the omitted information is not directly related to the final claim, if the insurer is unable to make a fair and accurate underwriting decision due to non-disclosure, they may refuse to pay.

Important Exclusions to Consider When Purchasing Health Insurance

Aside from accurately reporting health history, applicants should also be aware of the coverage and exclusions listed in the policy to avoid disputes when filing claims. Common exclusions include preventative treatments (like routine check-ups or screening procedures without symptoms) and pre-existing conditions. A pre-existing condition is typically defined as:

Any discomfort, illness, injury, physiological, psychological, or medical condition or functional decline that existed before the policy was issued or took effect, including congenital conditions. This definition may vary depending on the specific insurer or policy terms.

The following are considered pre-existing conditions:

• Diagnosed conditions

• Symptoms that are clearly evident

• Medical advice or treatment that was sought or received

Since pre-existing conditions are generally excluded from coverage, the insurance industry had been advocatingindividuals to purchase suitable health insurance while they are healthy to enhance their future protection.

Coverage of Unknown Pre-existing Conditions in Voluntary Health Insurance Plans

With the introduction of voluntary health insurance, coverage has expanded to include "unknown pre-existing conditions" (conditions that the customer was unaware of and should have been unaware of before submitting the insurance application). This feature is a significant selling point of voluntary health insurance plans.

Typically, standard voluntary insurance plans have a three-year waiting period for "unknown pre-existing conditions," with an increasing coverage ratio each year until full coverage is available starting from the fourth policy year. For specific examples, please refer to the table below.

• Policy Year

  Coverage Arrangement*

• 1st Year

  None

• 2nd Year

  25%

• 3rd Year

  50%

• From 4th Year

  100%

*Depending on the policy's coverage items and limits.

High-end voluntary insurance plans Voluntary Health Insurance Scheme usually have shorter waiting periods. For example, Cigna VHIS Series - Flexi Plan (Superior) provides comprehensive coverage starting from Day One of the policy. Regarding congenital conditions, coverage applies to conditions diagnosed or manifesting after the insured turns eight years old, provided they were unknown or unnoticed before purchasing the policy.

Applicants should follow the principle of "utmost good faith" by disclosing all health histories and issues to avoid unnecessary disputes when filing claims. If there are any questions regarding what to report, it is advisable to contact the insurance company early. CignaVoluntary Health Insurance Flexible Plan also offers a tax deduction of up to HKD 8,000 and various plan options to accommodate budget-conscious individuals, helping you maximize your savings.