Health Insurance Learning Hub
Understanding "Medically Necessary
According to the Insurance Authority, the definition of medically necessary in policy terms does not solely depend on whether hospitalization was recommended by a doctor. Insurance companies consider several factors to determine if a hospitalization meets the criteria for medical necessity:
Is the patient’s medical condition critical?
Is the hospitalization urgent or necessary?
Is hospitalization required for essential treatment or surgery?
Can the treatment be managed on an outpatient basis?
Is it difficult to conduct the treatment without hospitalization?
Is the hospitalization solely for diagnostic tests or symptom checks without treatment?
In other words, health insurance will only cover expenses arising from medically necessary services. Insurance companies will review claims based on generally accepted medical standards regarding the need for treatment related to the diagnosis or injury. Claims made solely for diagnosis or testing without a medical emergency, may be viewed as lacking medical necessity, which can affect the outcome of the claims process.
How to Define Medical Necessity in Hospitalization
The Insurance Authority provides the following example regarding hospitalization:
Ms. Lee (a pseudonym) was hospitalized for a full-body PET scan due to elevated tumor markers to rule out cancer. She later claimed the hospitalization expenses from her insurer. However, since the hospitalization was solely for the PET scan—which could have been performed on an outpatient basis—and no specific treatment was provided during her stay, the insurance company denied the claim, stating that there was no medical necessity for the hospitalization.
Coverage in VHIS Plans
For example, in a Cigna VHIS Plan, "medically necessary" refers to the need for medical services related to the diagnosis or treatment of injuries or illnesses, which must meet the following conditions:
Requires the expertise of a registered physician or referral.
Aligns with the necessary diagnostic and treatment needs of the condition.
Provided based on good and prudent medical standards and the professional judgment of the registered physician, not primarily for convenience of the insured, their family members, caregivers, or the attending physician.
Delivered in the most appropriate environment and facilities that meet generally accepted medical standards.
Offered at the safest and most effective level, according to the prudent professional judgment of the attending registered physician.
Since different insurance companies may interpret the criteria for medical necessity differently, policyholders should clarify the scope of coverage and exclusions of their policies before undergoing non-emergency hospitalization services.
Early Selection of Suitable Health Insurance
Choosing insurance that covers specialized outpatient services, surgeries, and other hospital treatments can help address unexpected health issues and provide future security.
Cigna VHIS plan offers various levels of coverage, with tax deductions of up to HKD $8,000, ensuring that every dollar spent on medical expenses is protected, manageable, and predictable.
Cigna VHIS Series - Flexi Plan (Superior) You need a smart voluntary health insurance policy:
Up to HKD 30 million in coverage annually, with no lifetime limit.
Tax deduction eligibility of up to HKD 8,000.
Comprehensive coverage for hospitalization, surgery, cancer treatment, mental health care, and more.
Learn More
The content above is for reference only. Cigna Healthcare does not guarantee the accuracy or completeness of the information provided. Cigna Healthcare is not liable for any damages, compensation, costs, or other expenses arising from the information herein.
The information about the insurance products is provided directly by Cigna Healthcare and does not encompass all coverage details and features of the insurance products. Specific insurance plans are subject to the terms of their policies. For product features, contents, terms, conditions, and exclusions, please visit the Cigna Healthcare website and refer to the relevant product brochures and policy terms. This information should not be considered a binding insurance contract or an offer, invitation, or solicitation to enter into any insurance contract.