Hospital Claims

Q1. Evaluation standard for "Normal and Customary" /"Reasonable and Customary" charge

We (Bupa) mainly refer to the fees of private hospitals, private healthcare facilities, the private service fees listed on the Hospital Authority's website, surgeons fee and the claims data that members submitted their claims in the past for the same type of surgery when evaluating "Normal and Customary" /"Reasonable and Customary" charges.

The difference of the cost of the surgeon's fee depends on the type and the complexity of the surgery, room level admitted in private hospitals, doctor's fees, length of hospital stay, etc.

Q2. The variance of medical expenses and its impact

For example, a common colonoscopy & biopsy, referring to the List of Private Services (Operations) on Hospital Authority's website, the reference price of MINOR II operations is around HKD12,750.00 to 19,350.00, the difference of the surgeon's fee between different doctors can be more than HKD50,000.00.

The variance on medical expenses would directly impact the claims payable amount as the benefit of customer. If the expenses are over than the eligible benefit limit, the customer is then required to bear the difference. If the expenses are less than the eligible benefit limit, the customer is then being fully covered by the policy and not required to bear on additional financial burden.

Aside of the direct impact on the payable able, the variance on medical expenses also contribute to the inflation of insurance cost. Insurance company has no way but to increase the premium to balance out the medical inflation, and customer will then face the high insurance premium.

For the sake of benefit of our customer as well as managing medical inflation, we strictly follow the principal on "Normal and Customary"/"Reasonable and Customary" charge. For instance, for certain claims with abnormally high medical expense, we will take reference from market standard, complexity of the surgery and the medical condition, and make necessary adjustment on the claims payable.

Q3. How is the "Normal and Customary"/"Reasonable and Customary" charge determined? If the medical expense exceeds the "Normal and Customary"/"Reasonable and Customary" charge, what will we do?

If the billed doctor's fee exceeds the “Normal and Customary"/“Reasonable and Customary" charge, we will obtain operation records from the relevant hospital or healthcare facility on case-by-case basis to understand the complexity of the surgery or any other surgery complication resulting in a higher surgeon's fee.

If the records reveal the legitimate reason behind the high surgeon's fee, we will calculate the eligible doctor's fee according to the billed amount and payable according to the policy contract.

If the records do not reveal any legitimate reason behind the high surgeon's fee, we will adjust the eligible doctor's fee according to the “Normal and Customary"/“Reasonable and Customary" charge and payable according to the policy contract. The portion of higher than the “Normal and Customary"/“Reasonable and Customary" charge will be rejected and listed as “non-covered item" on our Claim settlement Statement.

If you use a Bupa medical card, you don't need to pay for a hospital stay. Simply follow these steps:

If you choose a Bupa network specialist:

1. Before hospital admission: Consult a network specialist and your specialist will help you to obtain the pre-authorisation. Please allow at least 2 business days for pre-authorisation approval.
2. During admission: Show your Bupa medical card. Or you can use Hospital eAdmission^ on the myBupa app to send your medical card information to your selected hospital; then show your eMedical Card or confirmation QR code on myBupa. No hospital deposit is needed.
3. Before leaving the hospital: Please sign the claim form prepared by the hospital and pay the medical expenses with your Bupa medical card or eMedical Card^/confirmation QR code.

Bupa Gold members exempted

If you choose a specialist outside Bupa's network*:

1. Before hospital admission: Call us to obtain a pre-authorisation form (Bupa Gold members exempted). Ask your doctor to fill out the form and return it to us by fax, email or by post. We will issue a Pre-authorisation Confirmation / Guarantee of Payment Letter to your doctor and hospital. Please allow at least 2 business days for pre-authorisation approval.
   Pre-authorisation application:
   Email: preauthapp@bupa.com.hk
   Fax: 3973 6966
   Our office hours: 9am – 7pm, Monday – Friday, except public holidays
2. During admission: Show your Bupa medical card. Or you can use Hospital eAdmission^ on the myBupa app to send your medical card information to your selected hospital; then show your eMedical Card or confirmation QR code on myBupa. No hospital deposit is needed.
3. Before leaving the hospital: Please sign the claim form prepared by the hospital and pay the medical expenses with your Bupa medical card or eMedical Card^/confirmation QR code.

*Cashless service is not available for Bupa Crystal members if you choose a specialist outside Bupa's network.

For clinical operation or day-case surgery at a Bupa network provider:

1. Before treatment: Your network doctor will get pre-authorisation for you. Please allow at least 2 business days for pre-authorisation approval. (Bupa Gold members and Bupa Crystal members are exempted. This exemption doesn't apply to Bupa Safe members with Cancer Treatment Reimbursement Benefit.)
2. During registration: Show your medical card or eMedical Card^ on myBupa and the required documents:
• If pre-authorisation is needed, please present the approval document
• If pre-authorisation isn't needed, please present the specialist's referral letter
3. Upon discharge: Sign the voucher prepared by the provider and the Pre-authorisation Confirmation

^eMedical Card and Hospital eAdmission are currently available for selected insurance schemes only.