Hong Kong health care and hospitals

Hong Kong health insurance giant tightens reimbursement policy

AIA cites ‘excessive procedures’ but city’s largest doctors’ group cries foul

PUBLISHED : Sunday, 19 February, 2017, 8:47pm
UPDATED : Tuesday, 26 September, 2017, 10:45am

The biggest player in the city’s health insurance market has tightened its approval process for reimbursing “excessive health procedures” at private hospitals, prompting worries that patients’ rights could be undermined.

Other insurance companies are expected to follow the lead of AIA, whose health insurance premium has increased by more than 10 per cent annually due in part to medical claims abuse, according to insurance sector lawmaker Chan Kin-por.

The news surfaced as the insurance giant said in a letter to private doctors that it might no longer cover hospitalisation fees for “simple procedures” such as colonoscopy, gastroscopy and cataract surgery, which can be carried out at day care centres.

It added that its policy had been in place since 2014.

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The move met opposition from the Medical Association, the city’s largest doctors’ group, which defended the professional judgments of medical practitioners and accused the insurer of being irresponsible to its clients.

Some patients with high risk factors such as old age or chronic illnesses should be admitted to hospital for further observation even for “simple” procedures else their health could be at risk, the association’s Dr David Lam Tzit-yuen said.

“Doctors have a unique duty to diagnose and treat based on their clinical judgments,” he said. “The new insurance terms will inevitably take a toll on insured patients’ rights.”

The new insurance terms will inevitably take a toll on insured patients’ rights
Dr David Lam Tzit-yuen, Medical Association

Hong Kong Patients’ Voices chairman Alex Lam Chi-yau agreed, saying the move would cause more bill disputes between patients, doctors and insurers.

AIA’s letter, issued to around 500 private doctors last month, said the company wanted to “clarify” its policy on covering “medically necessary” procedures.

It suggested doctors recommend inpatient care only for medically necessary cases, listing seven significant comorbidity and five acute conditions for which hospital stays were allowed.

Three procedures – colonoscopy, gastroscopy and cataract surgery – were named as simple and encouraged at day care centres.

The letter also stated former health minister Dr York Chow Yat-ngok, an orthopaedic surgeon, had been appointed AIA’s chief medical officer and adviser.

A separate statement by AIA on Sunday said 90 per cent of cases the company handled over the past year involved hospitalisation, with an average health claim of HK$30,000 – three times more expensive than if they had been treated at a day care centre.

It noted a case in which a client failed in his HK$400,000 claim for gallbladder removal, which is usually HK$50,000 to HK $80,000.

A spokesman emphasised AIA respected doctors’ professional judgment, but said most could not explain why such hospital stays were necessary.

Chan, the insurers’ representative, said it was common for private doctors to carry out excessive health procedures on patients or to charge those who owned health insurance a higher fee.

“It leads to medical inflation, and premiums for health insurance will have to increase to cover the cost,” he said.

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Dr Gabriel Choi Kin, a former member of the Medical Council, said insurers should report complaints to the watchdog if it suspects doctors are carrying out unnecessary procedures.

Choi, who now chairs the Medical Association, said the watchdog had in the past received such complaints and that a doctor convicted of professional misconduct could lose his or her licence.

Pierre Chan, the medical sector lawmaker and a Ruttonjee Hospital specialist in gastroenterology and hepatology, said around 30 per cent of those who had gastroscopy required a hospital stay due to their age or health condition.

In 2015, total gross premiums in the city’s insurance industry amounted to $365.8 billion, following a 10.9 per cent increase from 2014, according to the Office of the Commissioner of Insurance.