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友邦保險（國際）有限公司致醫生信引發「醫療所需」權責誰屬的爭辯

背景

香港醫學會得悉，友邦保險(國際)有限公司於2017年1月27日致函私家醫生，信中強調，該公司的醫療保險賠償批出與否，需視乎該次住院有否「醫療所需」。

翻查友邦保險(國際)有限公司的契約條款， 本會發現該公司的「醫療所需」的定義如下：

「醫療所需 (Medically Necessary) 是指根據本公司意見，符合以下條件的醫療服務、程序或物品：(a) 與一般認可接受之專業醫療慣例一致；(b) 為診斷及治療所需，及 (c) 不可在較低醫療護理水平的情況下安全妥善地提供予受保人。 實驗性、普查及屬預防性質的服務或物品均不被視為醫療所需。」

簡而言之，該公司的契約條款規定，醫療所需」裁決權不在醫生而在保險公司。醫療程序或治療必須除醫院以外沒有其他可能時，住院才達到「醫療所需」的要求。

信中又指出，大腸內窺鏡、胃鏡、白內障手術即使要在監察麻醉下進行，均不屬於「醫療所需」住院進行的理由。

除非接受上述程序的病人另有住院的「醫療所需」而住院，否則該次住院費用或不獲賠償。  

信中所指的住院「醫療所需」包括全身麻醉(不包括監察麻醉)、需用上只醫院才有的醫療設備、七種重疾和五類急症。

七類重疾計有：

一、需要使用胰島素控制的糖尿病

二、需要使用流動氧氣的慢性阻塞性肺疾病

三、六個月內的新患中風或急性心肌梗塞

四、六個月內曾進行冠狀動脈旁路移植術、經皮冠狀動脈介入治療或治療中風的手術

五、正接受化療或輻射治療

六、心房顫動（不論是否裝置心臟起搏器）、陣發性心動過速

七、需要透析治療的腎衰竭

五類急症計有：

一、急性器官衰竭（心、肺、腎、肝）

二、急性腹部狀況（腹膜炎、爛尾炎、宮外孕等）

三、肺炎

四、急性心肌梗塞

五、中風

本會立場

(一)

本會必須指出，友邦保險(國際)有限公司的「醫療所需」並非醫學界接受的原則。醫生必須考慮適應症(indication)和禁忌症(contra-indication)為病人選擇診斷或治療程序，然後為病人安排合適的時間與場所，由合適的人士為病人進行該等程序。特別一提，醫生為病人選擇「合適」的場所進行醫療程序，不一定是可進行該些醫療程序的最低護理水平場所。醫生考慮的合適性，不等同最便宜的場所。

(二)

診病治療是醫生獨有的職責。醫生在作出臨床判定時，不應該以保險條款作為考慮因素。

(三)

不同病人，病情各異，即使進行同一個醫療程序，風險亦不盡相同。病人風險評估是一門重要的臨床學問，講究經驗，絕不是一些指引、一堆數字足以代表，更不能以七種重疾、五類急症約束之。

其實，重疾遠不止七種，急症遠何止五類！假如風險評估馬虎了事，醫療程序未在合適場所進行，併發症令病人受害甚至失救，責任在醫生。不少人士，雖不在「友邦十二類」內，並且看似健碩，但富經驗的醫生看到(未能乎合友邦保險要求的)潛在風險，為病人選擇醫院進行腸胃內窺鏡，實在是安全之選，可避免嚴重後果。

結語

保單契約條款是保險公司與其客戶之間的協議，原本與醫學界無關，但本會注意到醫療保險的條款與醫生行醫的原則大相逕庭，而信件撰寫人對醫療知識的掌握又明顯粗疏、膚淺，再考慮到醫療保險是香港私營醫療的重要融資渠道，深感是次友邦保險(國際)有限公司的信件影響深遠，對社會震盪巨大。

本會基於社會責任，決定站出來，向社會解釋，保障公眾的知情權，讓公眾人士在購買醫療保險前深思熟慮，多了解保險產品的性質和保障。

二零一七年二月十九日

編輯備忘：

香港醫學會成立於一九二零年，旨在聯繫政府、各公立醫療機構、大學及私人執業的醫務工作者，交流意見，團結一心。醫學會致力將最新的醫療資訊及醫務發展傳遞與會員，提倡會員遵行專業操守，進而服務社會，維護民康。

19 February 2017

PRESS

RELEASE

Debate on “Medically Necessary” arising from a letter to doctors from AIA

By way of a letter sent widely to doctors on 27 January 2017, AIA indicated “claims for procedures performed in [a] hospital when it is not ‘medically necessary’ may not be eligible for reimbursement for hospital confinement.”

According to policy terms of AIA, ‘medically necessary’ means that in the opinion of AIA, the medical services, diagnosis and / or treatments … cannot be safely delivered in a lower level of medical care.

In other words, the judgment as to what is ‘medically necessary’ lies with AIA and not the attending doctors.  Only when a procedure cannot be safely performed anywhere than a hospital will AIA consider hospital confinement ‘medically necessary’.

Three Medical procedures - Colonoscopy, OGD and cataract surgery were named to be simple enough to be safely performed in an outpatient setting.  Monitored Anaesthetic Care (MAC) was expressly excluded from the general indications for hospital confinement.

Unless patients undergoing the above procedures suffer from conditions that fall within the list of 7 types of ‘significant comorbidity’, according to AIA, claims for hospital confinement may not be eligible for reimbursement.

The letter listed 4 general indications for hospital admissions (acceptable to AIA), and these include general anaesthesia (excluding MAC), equipment required for a procedure is only available in a hospital and cannot be done on an outpatient basis, presence of a list of 7 types of comorbidity, and a list of 5 types of acute conditions that can only be managed in a hospital.  

The HKMA Position

We reject AIA’s notion of "medically necessary" as a valid concept. It should not be considered by doctors in making clinical judgment and decisions, including hospital admission.

Doctors consider INDICATION, CONTRA-INDICATION to decide whether a medical procedure should be carried out or not, and APPROPRIATENESS in deciding when and where such a procedure is to be performed.

Clinical judgment and decision remain the sole right and responsibility of doctors.

The listed comorbidity and medical conditions warranting admission produced by AIA are no more than examples of a much longer list of either category.  No such list can be exhaustive.    

In stark contrast to the seemingly safe profile lightly bushed away in the AIA letter, endoscopies and anaesthesia are not risk free. Serious, life threatening complications do occur albeit rarely.  MAC using intravenous deep sedation come with significant risks of airway loss, ventilation difficulty, aspiration and asphyxia. MAC borders on General Anaesthesia (GA), and it has sometimes been necessary to convert MAC into GA. Not only must these Anaesthetic procedures be taken seriously, but they must only be undertaken at premises where facilities allow for contingent intubation and mechanical ventilation. 

The most appropriate facility for an endoscopy with or without MAC is a fact sensitive, individualized clinical judgment.

Patient with comorbidities or suboptimal general Medical conditions far exceeding those listed in the AIA letter can only undergo endoscopy, MAC and intravenous deep sedation in a hospital setting. Clinical acumen is required to identify those risks, which do not subject themselves to classification or quantification.

Closing

While the limitation of reimbursement to AIA customers is a purely business consideration of AIA, the Medical profession considers it our social responsibility to make it known that the list produced makes no Medical sense.

Notes to editors:

The Hong Kong Medical Association, founded in 1920, aims to bring together Hong Kong's government, institutional, university and private medical practitioners for an effective exchange of views and co-ordination of efforts.  The foremost objective of the Association is to safeguard and promote public health.  The Association speaks collectively for its members and aims to keep its members abreast of medical ethics, issues and advances around the world.  In fulfilling these goals, the association hopes to better serve the people of Hong Kong.