Insurance companies will consider various factors when processing claims under medical or critical illness insurance policies. This video reminds policyholders to fully understand their policy coverage and terms, especially those related to the definitions of "medically necessary" and "reasonable and customary charges", before submitting a claim.

Many policyholders mistakenly believe that a doctor's referral letter or hospitalisation record will guarantee full reimbursement of all expenses. However, when assessing a claim, the insurer will also consider other factors, such as the urgency and purpose of hospitalisation, and the necessity of treatment. If the condition could be properly treated on an outpatient basis, or if no treatment or medication was administered during the hospital stay, the claim may be rejected according to the "medically necessary" clause. Therefore, for non-essential hospitalisation or medical examinations, policyholders should check the policy terms and claim details with their insurers or insurance intermediaries beforehand.

The "reasonable and customary charges" clause in the policy is also important during claim assessment. As different doctors or medical institutions have different pricing schemes for the same treatment, insurers will evaluate whether the claimed amounts are "reasonable and customary charges". For example, the Hospital Authority of Hong Kong provides a price list for medical fees and charges on its official website, and insurance companies can refer to it when assessing and deciding the amounts of claims. Therefore, policyholders may consider using the "pre-approval service" provided by the insurers to better prepare for the medical expenses.

Many insurance companies offer the "pre-approval service", which allows policyholders to obtain early approval from the insurers before undergoing medical treatments. It helps clarify the policy coverage and claim requirements in advance, so that policyholders can prepare better financially and avoid future disputes. Policyholders should also communicate with the insurers or insurance intermediaries before and after receiving medical treatments or hospitalisation to facilitate the claim submission.