Helen Tortoishell

Insurance issues


Many of us are covered by private health insurance and yet when it comes to making a cancer-related claim we can face problems getting the insurers to pay. Of particular concern is coverage for breast reconstruction following mastectomy and cover for elective surgery. Many Hong Kong-based and international policies exclude reconstructive or plastic surgery unless it can be classed as a medical necessity.


There is usually no definition of what a medical necessity means but recently one of our members had to deal with this issue. With the assistance of her surgeon she sent in her claim with a covering letter setting out the circumstances of her surgery. The member had a bilateral mastectomy with immediate reconstruction. Whilst she had been advised to have a left breast mastectomy, the right breast mastectomy was elective. Plastic or reconstructive surgery was excluded from the policy unless it was a medical necessity.


The surgeon involved explained that the bilateral mastectomy and the reconstruction were advised because without them there could be a need for further medical treatment to problems that might arise from a single mastectomy (such as posture and back issues). The surgeon did not state that this was a medical “necessity”, merely that it was advisable. The insurers accepted this and paid the claim in full.


The experience of other members has not always been so fortunate and there have been incidences of claims not being paid in full. Obviously much depends on the wording of the policy but as the above example shows, it is worth reviewing the policy cover in detail and then assessing how best to present the claim to the insurers. It is, for many of us, worth having a go anyway to see whether the boundaries can be pushed.


With the cost of surgery being so high, any information we can share about insurance coverage will benefit us all.