Coverage may not always be of benefit

THE bottom line is, if you are ill, you want someone else to pay. But comprehensive cover is not something that can be taken for granted even if coverage is by a company insurance scheme.

''This is a mistake I see made often in Hongkong,'' said Mr Keith Pearson, managing director of BUPA and former chairman of the Medical Insurance Association of Hongkong.

Misconceptions about coverage were problems which faced insurance companies, employers and employees, he said.

''In Britain, plans are made according to the maxim that they should be fit for the purpose for which they are intended - a fair test of the product.

''It's no good paying a few hundred dollars for benefits if the employer's intention is that their employee should have a private bed.'' Insurance schemes can give a false sense of security, where a ''benefit'' to the employee can become a liability. Many companies operate a credit card type system where patients sign a bill at the end of their stay. Depending on the arrangement the company has with the insurers, any amount outside the range insured could be billed back to the employee.

Slowly employers, employees, insurers and the medical profession are waking up to this cold comfort, according to Mr Pearson.


''Insurance does not insulate them from medical costs, it is no panacea,'' he said.

''When possible, policyholders should check with the doctor and the hospital before starting treatment.

Unlike life insurance, medical insurance, whether group or individual, deals with the present rather than the future. With inflation, premiums are likely to increase annually and, if employers fail to expand coverage, they will fall behind in terms of real cost.

Medical insurance works on a reimbursement basis which Mr Pearson felt was not the most cost-effective way of handling health care in a rapidly maturing private sector.


''An alternative would be 'preferred provider' options, whereby an insurer would negotiate fees with hospitals for room and board and agree set fees with doctors and consultants,'' he said.

''If the customer goes to the preferred doctor he will be reimbursed 100 per cent.


''Otherwise, he may be reimbursed up to, say, 80 per cent.'' It is this lack of availability of comprehensive cover that makes the private sector so vulnerable at present, Mr Pearson added.

''If the risk to the policyholder could be eliminated, the private sector would grow much quicker,'' he said.

''This would have a massive impact on the public sector so that those who could not afford private health care could receive better care more quickly.'' In Hongkong, fees for doctors, particularly surgeons, and hospital costs which account for the biggest portion of expenses, have no standard guidelines.


Fees are largely at the discretion of the surgeon depending on the complexity of each operation.

Insurers feel they are reluctant to have their fees ''dictated'', making it difficult for insurers to provide comprehensive coverage.

''The business at present is a mess,'' Mr Pearson said.


''People have a right to expect the insurance and medical community to talk to each other and find ways to provide comprehensive cover.

''One consumer on his own can do nothing but all of them represented by the insurance companies should expect a hearing.'' Mr Nick Donne, chairman of the Medical Insurance Association of Hongkong, said that insurers had tried to encourage the medical profession to publish such guidelines but, in an interview last year, Dr David Fang Jin-sheng, president of the Hongkong Medical Association, suggested a fee schedule would be against the public interest.

He said that the relationship between doctors and the Medical Insurance Association had been hurt by what he considered to be a misunderstanding.

However, he suggested that an annual survey of surgical fees could provide a guideline for the public and medical profession.