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<Prudent Strategies in Taking Out Medical Insurance> pdf (Chinese Version only)
Smart Tips |
Congenital Conditions / Anomalies In general, medical insurance intents to cover an Insured for event that happens after a policy has been effective. As a congenital condition / anomaly is existing at the time of birth, it is therefore pre-existing to the effective date of a policy and is usually excluded from medical insurance coverage. Congenital Conditions / Anomalies means medical abnormalities existing at the time of birth, known or unknown, regardless of the time of discovery or the time of treatment. Examples of Congenital Conditions / Anomalies are birthmark, cleft lip or palate, club foot, septal defect of heart, undescended testicle and arteriovenous malformation. |
Things You May Want to Know About Congenital Conditions
Ms. Chan was a 35 year old housewife. She found a palpable asymptomatic mass in her neck which increased in size for one month. The mass was confirmed to be a "thyroglossal cyst" by doctor. The doctor advised Ms. Chan to be admitted for surgical excision of the cyst. After the operation, Ms. Chan filed a claim to insurance company for the cost of hospitalization. The insurance company declined her claim based on the ground that her hospitalization was for treatment of “congenital condition” which fell under the general exclusions of the policy.
As Ms. Chan did not have any swelling over her neck at birth or during her childhood, she thought her condition should not be congenital.
According to the policy provision, "congenital condition" means "medical abnormalities existing at the time of birth, regardless of whether they are known or unknown to the insured".
"Thyroglossal cyst" results from incomplete closure of thyroglossal duct as the embryo develops. The thyroglossal duct should normally close completely as the embryo develops. If the duct has not closed completely, it will result in the formation of cyst.
Although the cyst was not present at the time of birth of the insured or during her childhood, the medical abnormality that gave rise to "Thyroglossal cyst" did exist at the time of birth. Therefore, the insurance company declined the claim in view that the illness is a "congenital condition".