Using medical insurance for a private specialist: medical networks, pre-approval (cashless) and making your own claim
Before seeing a private specialist, confirm three things with the insurer: whether the policy covers specialist outpatient visits, whether it is limited to a designated medical network, and whether a referral letter or pre-approval is needed. For a hospital stay, if both the policy and the hospital offer direct billing, you can apply for pre-approval before admission and the insurer pays the hospital directly; for outpatient visits you generally pay first and then claim with receipts and other documents.
How do I pay when using insurance?
| Situation | How to pay | What to prepare |
|---|---|---|
| Hospital stay with pre-approval granted (ask the insurer whether day surgery is included) | The insurer pays the hospital directly under the ‘guarantee of payment letter’; items not covered must still be paid by you | Apply before admission, within the number of working days specified by the insurer; on admission, bring the ‘preliminary coverage assessment confirmation / guarantee of payment letter’ issued by the insurer |
| Hospital stay without pre-approval | Pay first, claim after discharge | A claim form completed by the attending doctor and stamped by the hospital, the original hospital receipts, and copies of medical or laboratory reports |
| Specialist outpatient visit | Generally pay first, claim afterwards | Claim form, original receipts, and a referral letter (if applicable) |
Does the Voluntary Health Insurance Scheme cover specialist outpatient visits?
The Voluntary Health Insurance Scheme covers only individual indemnity hospital insurance; outpatient insurance, non-indemnity insurance such as hospital cash, and employers' group insurance are outside the Scheme.
The Standard Plan's pre-admission or post-discharge / pre- and post-day-surgery outpatient cover: up to 1 outpatient or emergency consultation before a hospital stay or day surgery, and up to 3 follow-up outpatient visits within 90 days after discharge or day surgery (which must be directly related to the illness or injury for that hospital stay or day surgery), at HK$580 per visit and HK$3,000 per policy year; during prescribed non-surgical cancer treatment, specialist outpatient charges for treatment planning and monitoring of disease progress are covered separately under that benefit item.
The Standard Plan also covers prescribed diagnostic imaging tests recommended in writing by the attending registered doctor and carried out during a hospital stay or as a day patient (at a clinic, day surgery centre or hospital), namely CT, MRI, PET and combinations of them, up to HK$20,000 per policy year, with 30% coinsurance payable by the policyholder.
Specialist outpatient visits not related to a hospital stay, day surgery or prescribed non-surgical cancer treatment are not covered by the Standard Plan; a Flexi Plan or separate outpatient insurance may cover them, depending on the policy.
What is a medical network?
The basic cover of a Voluntary Health Insurance Scheme certified product must allow free choice of hospital and doctor; the enhanced cover of a Flexi Plan may apply only to certain hospital and doctor networks.
We suggest confirming with the insurer before seeing a doctor: whether the doctor or hospital is in the network, and whether reimbursement differs inside and outside the network.
How does pre-approval (cashless) work?
What is commonly called ‘cashless’ is termed ‘pre-approval’ by the Insurance Authority: some insurers offer this service, in which the insurer pays the healthcare institution directly and the patient brings the ‘guarantee of payment letter’ issued by the insurer on admission.
The pre-approved amount is an estimate, and the final reimbursement depends on the claim outcome. For example, St. Paul's Hospital explains that before discharge the patient must still pay charges not listed in the ‘guarantee of payment letter’, such as the deductible, co-payment and charges outside the scope of cover.
Before treatment, the policyholder can attach the hospital's or doctor's fee estimate and ask the Voluntary Health Insurance Scheme insurer to estimate the amount that can be reimbursed; the estimate is for reference only.
Hospital licensees must set up a budget estimate system for the treatments and procedures prescribed by regulation (Private Healthcare Facilities Ordinance, section 62). In addition, under the Department of Health's Pilot Programme for Enhancing Price Transparency for Private Hospitals, the Department of Health has recommended 30 common non-emergency treatments and procedures for which hospitals and doctors can provide a budget estimate of the service fees before admission. We suggest asking the hospital to provide it in writing. For private consultation fees in the eight common specialties checked by this site, see Private specialist consultation fees overview.
How do I claim for an outpatient visit?
For small claims such as outpatient visits, you generally submit the originals of the claim form, receipts and referral letter (if applicable); some insurers accept electronic submission.
The claim deadline is generally 30 to 90 days after the consultation or discharge, and late claims may be rejected; for Voluntary Health Insurance Scheme certified products, the claim deadline is not less than 90 days.
Insurers reimburse according to ‘reasonable and customary’ charges; before treatment you can compare fees, or ask the insurer whether a fee is reasonable.
Common misconceptions
‘If I have Voluntary Health Insurance Scheme cover, specialist outpatient visits are covered’: no. The Standard Plan does not cover stand-alone specialist outpatient visits; it covers only outpatient visits before and after a related hospital stay or day surgery, and specialist outpatient visits during prescribed non-surgical cancer treatment.
‘The pre-approved amount is the final reimbursement’: no. Pre-approval is an estimate, and reimbursement depends on the final claim outcome.
‘If a doctor refers me for admission, the insurer will treat it as medically necessary’: not necessarily. A doctor's referral does not in itself mean that a hospital stay is medically necessary; before a non-emergency admission, confirm the cover and exclusions with the insurer first (Insurance Authority, January 2024).
Frequently asked questions
Does the Voluntary Health Insurance Scheme pay for a private specialist outpatient visit?
The Standard Plan does not cover stand-alone specialist outpatient visits; it covers only outpatient visits related to a hospital stay or day surgery (up to 1 before and up to 3 within 90 days after, at HK$580 per visit and HK$3,000 per policy year), and specialist outpatient visits during prescribed non-surgical cancer treatment. For stand-alone specialist outpatient visits, look at a Flexi Plan or separate outpatient insurance.
What is pre-approval?
A service offered by some insurers: the patient applies before admission, within the number of working days specified by the insurer, and once approved the insurer pays the healthcare institution directly. Pre-approval is an assessment, and the final reimbursement depends on the claim outcome; charges not listed in the ‘guarantee of payment letter’, such as the deductible, co-payment and charges outside the scope of cover, must still be paid by you.
What documents do I need for an outpatient claim?
Generally the claim form, original receipts and a referral letter (if applicable); some insurers accept electronic submission. The claim deadline is generally 30 to 90 days after the consultation.
Can non-Hong Kong residents buy Voluntary Health Insurance Scheme cover?
Yes, but insurers can decide for themselves whether to accept non-Hong Kong residents as insured persons; the policy is eligible for a tax deduction only if the insured person is a Hong Kong resident.