The main purpose for enrolling in medical insurance is to enjoy comprehensive medical protection and coverage, especially when you need to stay in hospital for further treatment. Medical insurance can help share the burden of hospitalisation expenses. Some people may misunderstand that as many hospitalisation expenses claims are covered in full, up to the maximum aggregate amount as stated in their policy, their own share of the surplus expenditure shall be limited even if they choose to stay in a hospital ward with daily room and board rates exceeding their cover limit. However, this may not be correct.

Ms. Kwok was admitted to hospital for minor surgery and stayed for one day. As Ms. Kwok had enrolled in a medical insurance plan, she decided to stay in a semi-private room at HK$2,500 per day instead of a ward at HK$1,800 per day to ensure a more comfortable environment for recuperation. Ms. Kwok then submitted a claim form for hospitalisation expenses to her insurer after being discharged from hospital. She expected that she could get back most of her hospitalisation expenses of HK$12,100. However, her insurance company only reimbursed HK$9,216 of her claim. Why couldn't Ms. Kwok get the full reimbursement she expected?

With regard to Ms. Kwok’s case, please refer to the chart below:

As Ms. Kwok upgraded from a ward to a semi-private room, the actual expenses of room and board exceeded the maximum limit stated in Ms. Kwok’s policy. At the same time, other related expenses went up according to the class of room she chose. According to the provision of Ms. Kwok’s medical insurance policy: “If an Insured Person is confined to hospital accommodation exceeding the Room & Board entitlement stated in the table of Benefits, the amount payable for Hospital Treatment & Services will be adjusted according to the following factor: (Daily rate of Room & Board entitlement) divided by (actual daily rate of Hospital accommodation incurred) times 100%.” i.e. (HK$1800/HK$2,500) x 100% = 72%, which means that apart from the expenses of Room & Board which can be covered to its original maximum limit, all other expenses will be compensated in the same proportion.

To avoid any disputes and ensure that hospitalisation expenses will not exceed their expectations, customers are advised to choose a suitable medical insurance plan that meets their desired level of accommodation and select an appropriate room that is fully covered under the “Room & Board” Benefits they are entitled to.

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