We are committed to providing our customers with sustainable medical insurance services. To that end, we would like to inform you about the governing principles of our claims management process.

We enforce the "Reasonable and Customary Charges" and "Medically Necessary" clauses for all medical service claims.

Reasonable and Customary Charges refers to the charges for hospital confinement, treatment, procedures, supplies, or other medical services that are medically necessary and do not exceed the general level of charges in the local area for similar diseases or injuries. If the costs exceed the reasonable and customary charges, we will only reimburse the amount corresponding to the reasonable and customary charges.

This clause is based on the principle that medical charges should be both medically necessary and reflective of prevailing charges in the local healthcare market. We determine this by referencing fees from private hospitals, healthcare facilities, private service fees listed on the Hospital Authority's website, and claims data submitted by members for the same type of medical services in the past.

Medically Necessary means that the hospital confinement, treatment, procedure, supplies, or other medical services are required for the diagnosis or direct treatment of a disability. By applying this clause to hospital confinement claims, we aim to prevent unnecessary hospital admissions and ensure that our customers receive appropriate and necessary care.