Go to Hong Kong to buy insurance? Hehe, there is only one reason to claim compensation, and there are 1000 reasons to refuse compensation.

On 20 18 12 12, Chen Fei (pseudonym) received a reply from the Prudential Personal Life Insurance Administration of the United Kingdom, informing him of his application for serious illness claims. Upon examination, the policy is invalid. The result, completely surprised Chen Fei.

20 15 In May, Chen Fei insured the Prudential Life Insurance Plan for Major Diseases (insured amount 100000 USD)-additional free critical illness insurance 10 years (insured amount: 35000 USD) in Hong Kong through his wife's colleague and a part-time insurance agent.

Chen Fei, who has been deeply involved in the media and financial industries for many years, has been studying insurance. "At that time, I felt that Prudential's products covered many diseases, involving very early cancer. Considering that the US dollar is in a strong cycle, I think this policy is very appropriate. "

Because both parents died of cancer, Chen Fei has a physical examination every year. In 20 18, Chen Fei examined the ground glass nodule in the right middle lung of the chest (there was no problem in the previous lung examination), and then the right lobe was resected on September 20 18 18, and the cancer in situ was 2 mm

After leaving the hospital, Chen Fei sorted out the health information and negotiated with Prudential for settlement of claims. Unexpectedly, the insurance company actually replied that this situation would not be settled. The reason is that the insurance company learned that Chen Fei showed right external auditory canal embolism, pharyngitis, binocular amblyopia and mild fatty liver in the physical examination on August 12. August 3 1, 2065438, physical examination showed that the body mass index was higher than normal, hemorrhoids, rhinitis, hepatic hemangioma and thyroid nodules. Because the above information was not stated in the previously signed life insurance application, we refused to pay compensation and cancelled the policy.

In fact, it is not uncommon for Chen Fei to be refused compensation. Many mainland customers who bought Hong Kong insurance for themselves or their families refused to pay because of the incomplete disclosure of important facts, and then fell into long complaints and wrangling.

Some people refused to pay compensation when they were diagnosed with coronary heart disease because they saw dizziness, tinnitus, chest pain, rash, left scapular pain, oral ulcer, folliculitis and other diseases in the hospital outpatient department within 5 years before insurance. Some people applied for compensation for lung cancer after years of insurance, but the insurance company refused to pay compensation on the grounds that there were intravenous injection cases for three consecutive years before insurance. As the saying goes, "there is only one reason for claiming compensation, and there are 1000 reasons for refusing compensation." Some users have no choice but to comment that Hong Kong insurance is a "big pit where compensation can be refused a little bit".

But is this a misunderstanding or deception by insurance companies or agents?

"You don't have me."

"I go to Hong Kong to buy insurance on weekends." Once upon a time, this was one of the most popular greetings for the middle class in the mainland.

In the past ten years, mainland customers have gone to Hong Kong to buy insurance, especially those based on critical illness insurance and savings and wealth management insurance. 20 15 agents and cooperative institutions of mainland financial institutions, P2P companies and Hong Kong insurance companies began to sell Hong Kong insurance in the Mainland.

From 2007 to 20 16, the new policy premiums of mainland visitors jumped from HK$ 5.249 billion to HK$ 72.688 billion, and the proportion of new policy premiums of mainland visitors in the overall new policy premiums of Hong Kong insurance industry climbed from 6.54% to 40.59%. According to the data of the China Insurance Regulatory Commission, from 2006 to 20 16, mainland residents bought13591400 million Hong Kong dollars (about1/682.4 billion RMB) insurance in Hong Kong. About 96% of them are medical or insurance products, such as critical illness, medical care, whole life insurance, term life insurance and annuity.

What's the difference between Hong Kong insurance and mainland insurance?

1949 China people's insurance company was established, 1979 began to resume insurance business in the mainland. At that time, PICC was the only insurance company. It was not until 1988 that Ping An Insurance was formally established. At that time, it was nearly 10 years since the wave of reform and opening up. It has been 40 years since the real insurance industry in mainland China made a fortune.

In contrast, the insurance industry is one of the oldest commercial industries in Hong Kong. 184 1 year, the first insurance company in Hong Kong was born during the Opium War. Compared with the property insurance business, the development of life insurance is relatively backward. Even so, the first life insurance policy in Hong Kong was born in 1898.

There is a time difference of 100 years between the two markets, which means that Hong Kong insurance has been tempered and tested for a longer time in terms of product maturity and richness, as well as the completeness of legal and regulatory systems. In addition, most of the insurance companies operating in Hong Kong are large multinational insurance companies, and the whole product design model is calculated based on the average life expectancy and disease probability in Hong Kong (the average life expectancy in Hong Kong is 85 years, and that in China is 75 years, and the incidence of some diseases in Hong Kong is lower than that in China). Therefore, more comprehensive protection, low premium and high income, high integrity and global asset allocation have become the advantages of Hong Kong insurance.

"Under normal circumstances, we will introduce Hong Kong insurance to our customers. Compared with similar mainland insurance, we have basically achieved that you have nothing, you have me. " Xu Yun is one of the independent agents engaged in Hong Kong insurance agency in the Mainland. She showed the difference between AIA's two products.

Hong Kong AIA's "Yujiazhi Bobby" also has a basic insurance coverage equivalent to RMB 2 million. Under the standard of 35-year-old male (non-smoker), the annual premium of Yujiazhi Bobby is 62,400 yuan, the payment period is 18, and the total premium is1120,000 yuan. The annual premium paid by Quanyou Zhizhen is 10 1600 yuan, the payment period is 19, and the total premium paid is1920,000 yuan.

In addition to the price difference, there are also differences in coverage and excluded liability, disease category and surrender value. Xu Yun explained: "Take death claims as an example. Except for suicide within one year after purchasing insurance, Jiashuang Insurance can take risks regardless of death caused by illness, accident, suicide or terrorist attack. Quanyou Zhizhen claims for deaths caused by diseases, accidents and suicides, including crimes, drunk driving, unlicensed driving, riots, military conflicts, nuclear radiation, drugs, and suicide within 2 years. "

Xu Yun said that in the comparison between Hong Kong insurance and mainland insurance, the difference between critical illness insurance is the most obvious. In recent years, most mainland customers who contact or trade insurance policies are young and middle-aged users aged around 30-35. The differential protection of Hong Kong insurance is the key reason why they finally choose Hong Kong insurance.

"Users will take the initiative to ask about the comparison between insurance clauses, and will also view the scope of disease protection in a targeted manner." Xu Yun said that the scope of disease protection and insurance forms in Hong Kong are more diverse. "In terms of critical illness claims, the coverage of insurance in Hong Kong is indeed more humane and diversified. Most of the diseases covered by insurance in Hong Kong reach hundreds, while in the Mainland, there are about 50-80 diseases, and now some of them reach hundreds. In terms of claims, Jiayu Zhishuang Insurance has set up two additional claims for cancer recurrence, and the amount of compensation can reach 80% of the insured amount, which means that the entire insurance coverage can provide up to 260% of the insured amount, and cancer can be settled at 1 period. "

There are also some insurance products that are unique to Hong Kong. For example, Prudential recently launched cancer rehabilitation insurance to provide cancer protection for cancer rehabilitation patients. "For users with different physical conditions, Hong Kong insurance provides a possibility. Simply put, it is to buy more health insurance with less money. " Xu Yun bluntly said that this is an advantage for customers, but the opposite insurance company will face more risks and unknowns, and the possibility of adverse selection in insurance will be greatly improved. From the business logic, insurance companies need to design enough claims clauses and insurance principles for themselves. "At this level, the information asymmetry between customers and insurance companies is very serious."

The guarantee of "you have nothing, you have my superiority" has also been fully followed in the provisions of insurance risk control and compliance regulations, which has also become the fuse of a large number of subsequent refusal disputes.

Claiming misfire

"Hong Kong insurance is really hot in the mainland market, which is a step in the rise cycle of the middle class. These users have more protection awareness and risk awareness than their early insurance customers, but they do not have professional medical and underwriting knowledge when they apply for insurance. It's really easy to step on the pit. " A person in charge of the compliance department of a domestic insurance company told the reporter, "The insurance clauses in Hong Kong are complicated in design, and few customers can scrutinize them carefully. In addition, commercial profit-seeking has led to the barbaric explosion of insurance agents in Hong Kong, selling a group of unprofessional people who don't understand Hong Kong insurance to a group of customers who also don't understand products. "

In fact, regarding the uncertainty of insurance and dividend distribution in Hong Kong, there are few designated hospitals for medical treatment in the Mainland, and the differences in product details such as thyroid diseases are mild (severe in the Mainland) are gradually recognized. Compared with these, the biggest headache for mainland customers is the various "unexpected" aspects of key claims.

Before Chen Fei, with the shortening of the purchase cycle, Hong Kong's refusal of insurance has occurred one after another. The most heated issue is the complaint of pulling banners in Hong Kong Harbour City in April 20 18. The reason is that a mainland customer insured a critical illness insurance and medical insurance for his children in an insurance company in Hong Kong on 20 15. From February, 20 16 to September, 20 17, the child was hospitalized for 6 times due to illness and successfully applied for medical insurance claims. From 2065438 to September 2007, the child was diagnosed with leukemia during the seventh hospitalization, and was refused compensation when claiming from the insurance company. His child's medical insurance policy had to be cancelled because he had been hospitalized and had not told the truth when he was insured. The basis of hospitalization is the first hospitalization caused by acute upper respiratory tract infection and secondary thrombocytopenia when the child is 1 year old.

As the insured, the customer, after receiving the results of the insurance company's refusal, appealed to the insurance company and the financial advisor respectively, and the insurance company maintained the refusal. This incident has aroused discussion in the insurance circle, especially in the mainland insurance industry, and also sounded the alarm for those customers who have loose misunderstandings about insurance claims in Hong Kong.

Among the many Hong Kong insurance agents contacted by the reporter, "strict entry and lenient exit" is the advantage of Hong Kong insurance. In other words, the health underwriting of insurance is relatively strict. Once the underwriting is passed, it will become the insured and insured of Hong Kong insurance, and the available claims service is also convenient and relaxed. "I'm not talking to you. I don't care about small money." This view will be repeatedly emphasized in almost all purchase processes.

In the actual transaction scenario, most customers completely underestimate or deliberately conceal the "strictness" of Hong Kong insurance when purchasing products described by Hong Kong insurance and agents.

In Hong Kong, compensation disputes below HK$ 6,543,800+000 can be appealed to the Insurance Compliance Bureau, and the above-mentioned Harbour City incident is beyond its jurisdiction. In addition, although the insured has indicated that he was serving his sentence at the time of insurance, he has sufficient reasons to prove that he did not know the child's first visit, so it cannot be regarded as an important fact that has not been made public.

"But in fact, the two answers of' I don't know' and' I don't know' are completely different in legal sense." The person in charge of the compliance department of the above-mentioned domestic insurance companies said that in Hong Kong's insurance laws, many insurance clauses seem to be arbitrary, but in fact they are obviously different from those in the Mainland. The insurance company may only have the option of yes or no regarding whether it has seen a doctor, but the insured does not know or know, so it is necessary to communicate and negotiate with the insurance company again. This requires the insured to have a high level of knowledge in law and medicine.

"Buying and selling insurance, whether in the mainland or in Hong Kong, must abide by the principle of utmost good faith, that is, when applying for insurance with an insurance company, the applicant should fully disclose all important facts about the insurance, and there is no fraud or concealment. The insurance company will decide whether to accept (or how to accept) the application of the insured according to all the important facts declared by the insured. "

However, due to the different legal systems in the two places, the differences in some terms directly lead to the worldwide differences in claims settlement results. For example, the mainland insurance law emphasizes limited notification, and the insured only needs to answer the questions raised by the insurance company. Hong Kong insurance, on the other hand, implements unlimited notification. No matter whether the insurance company asks or not, the customer needs to take the initiative to inform, otherwise the insurance company has the right to refuse compensation. "This is also the legal basis for why you can still refuse compensation without knowing or knowing."

In addition, under the supervision of mainland insurance, there are irrefutable clauses after two years. The simple explanation is that insurance companies have a two-year review period. In the above-mentioned Harbour City incident, when the first medical insurance claim was made, the insurance company knew all the facts by default, and it took more than two years to sign the contract when applying for the critical illness insurance claim. In the mainland insurance law, it is theoretically necessary to pay compensation. However, there is no such provision in Hong Kong insurance, and refusal to pay compensation is also legal.

The situation in Chen Fei is similar. It has been four years since the policy came into effect, and various problems in the reasons for refusing insurance are not deliberately concealed. "When I was insured, I also asked if I needed a medical examination and whether I needed to provide a previous medical examination report. The reply was no. Just fill in the form truthfully. Moreover, the past history mentioned has nothing to do with lung disease. "

"The industry will emphasize the purchase of insurance, especially when it comes to medical care. It is not as simple as buying protection, but choosing a financial product with both medical and legal attributes. This is a relatively high threshold and risk. All visa refusals are based on the contractual agreement and the legal basis behind it, which is why customers find it difficult to defend their rights afterwards, because everything happens for a reason. " During the reporter's consultation with the staff of the Compliance Department, he said frankly, "The basis of many people's complaints is that ignorance or concealment of medical history has nothing to do with the disease diagnosed at the time of claim settlement. In fact, in our opinion, if we make a ruling according to this understanding, all people with a past medical history can take out insurance in spite of illness, and insurance will completely become speculation, which is why problems such as hemorrhoids, amblyopia, fatty liver and thyroid nodules will become reasons for refusing insurance. "

At the same time, he added that the insurance law in the Mainland relatively protects the interests of the insured. Regarding the matters that the customer did not tell the truth and the subsequent claims for illness, the principles of local courts in handling cases are different.

"Some courts support the theory of causality, some courts support the theory of no causality, and there are related precedents." For example, he said, for example, a client didn't tell him about thyroid nodules, and finally he was diagnosed with gastric cancer. When he was insured for critical illness, he was refused compensation by the insurance company. "The interpretation of the Shanghai court is generally in accordance with the original intention of legislation (like Hong Kong), as long as it is enough to affect the underwriting of insurance companies or increase the rate, it is the content of health notification required by insurance companies at that time (whether there are thyroid nodules), but you did not tell the insurance company. Regardless of any disease, whether it is related to thyroid nodules or not, the insurance company can cancel the contract and refuse to pay compensation. However, some courts in other provinces and cities believe that there is no causal relationship between what customers have not told and the final gastric cancer (which is not supported by existing medical theory and practice), and they still tend to pay compensation. There is room and room for manoeuvre. "

Chen Fei used to negotiate and complain with the insurance company together with the agent. Prudential's opinion is that the policy will be invalid immediately because the thyroid nodules were not reported truthfully.

Chen Fei dug out the insurance policy, and in "Health Status-Please answer the following questions about health status", one of them wrote: Diseases related to respiratory system or endocrine system, such as asthma, bronchitis, emphysema, diabetes or goiter.

"When filling out this form, I don't understand the situation of goiter. Before the insurance (20 15), it was clearly stated in the physical examination of Shenzhen Sixth People's Hospital 201,Peking University Shenzhen Hospital 20 12 and Shenzhen Aikang 20 14 that there was no goiter. " Moreover, it is clearly stipulated in the underwriting guidelines that if the thyroid nodule is clinically diagnosed as a benign thyroid nodule, surgery is not needed for the time being, and underwriting can be ruled out.

In fact, this is also the difference between Hong Kong insurance and mainland insurance underwriting. Generally, customers who take out insurance in the mainland will explain various problems in detail if they read the insurance contract carefully, and list the names of specific diseases in the health notification section, for example, whether the number of cigarettes smoked per day x the age of cigarettes (year) >; 400? Whether there is hypertension (systolic blood pressure 140mmHg or diastolic blood pressure above 90mmHg), whether there are endocrine system diseases, such as diabetes, gout, thyroid diseases, etc. And the words that often appear in the health notice of Hong Kong insurance are broader, such as whether there is goiter? Are there any blood diseases? Are there any accidents or diseases not mentioned above?

In the case of uncertainty, quantitative description or differential expression, Hong Kong insurance companies will also require the implementation of the principle of unlimited notification, and all past anomalies need to be truthfully informed, such as "Have you had an accident or suffered from an illness in the past five years without mentioning it?" This increases the uncertainty of the insured.

The person in charge of the above-mentioned compliance department said that it is difficult for the insured to distinguish the details in the text, and many agents know little about these details: "In order to sign the bill, there are indeed cases in which the agent did not inform the customer of all the information, and there are also cases in which the agent refused to pay compensation because it was not professional enough in the subsequent claim settlement process. In particular, some agents who represent Hong Kong insurance in the Mainland are not clear about the notice. Coupled with the high liquidity, it is easy to have problems when underwriting services in the future. "

An interviewee who has been the head of actuarial department in both Hong Kong and mainland insurance companies told reporters: "Many people will go to Hong Kong to buy insurance because of its high return on investment and high cost performance. After all, insurance is a long-term product, not a consumer product that can be used tomorrow. The test is the timeliness and convenience of providing services. In fact, the regulatory environment in the Mainland is much stricter than that in Hong Kong. Supervision is often judged from the customer's point of view, especially in claims settlement. In mainland litigation, 90% of insurance companies lost the case. "

"In many reports or complaints, we will avoid the heavy weight, don't talk about the law, and blindly sympathize with the weak. Insurable adjudication is not a single event. Customers have the position of customers, and insurance companies have the position of insurance companies. I have encountered a case ruling that the definition of cancer in Hong Kong is different from that in the Mainland. " The above-mentioned compliance department said that except for medical insurance with a claim amount of less than 3,000 yuan, it is a small payment in the regulatory regulations and is the most refreshing payment. For other sickness insurance, each insurance company has a cost balance. The most important consideration is whether there is enough evidence to refuse insurance. If the evidence is insufficient, the insurance company will weigh the corresponding supervision cost (customer complaint supervision) and reputation risk cost (media exposure).

"In addition, some small and medium-sized companies' critical illness lists will have insurance coverage settings. Once the claim is higher than this, it will basically be reinsurance, that is, the premium will be distributed to the reinsurance company. Once the reinsurance company finds that there are doubts about the claim, as long as it can refuse to pay, it will definitely refuse to pay, even if the insurance company is involved in the investigation. "He emphasized that this was not" cheating "." Whether buying mainland insurance or Hong Kong insurance, the most important thing is to distinguish between the purpose of financial management and the purpose of protection. The dividend income of the former is the focus, but the insurance is different. The definition of medicine, legal provisions and the scope of medical services are all different. "

Demolition of walls and dwellings

With the gradual exposure of various problems, after a decade of skyrocketing, the enthusiasm of mainland customers to buy insurance in Hong Kong has been extinguished in the past two years. Since 20 17, the insurance market in Hong Kong has cooled rapidly.

The performance of Hong Kong's insurance market in the first three quarters of 20 17 released by the Hong Kong Insurance Regulatory Commission first mentioned the details of mainland tourists' insurance coverage. According to the data, the new policy premiums of mainland tourists decreased from HK$ 188.9 1 000 and HK$ 23.7 billion recorded in the third and fourth quarters of 20 16 to HK$1880.7 billion in the first, second and third quarters of 20 17.

In 20 17, the new policy premiums brought by mainland tourists reached HK$ 50.8 billion, which was the first significant drop in seven years compared with HK$ 72.688 billion in 20 16. According to the latest data, as of the first half of 20 18, the new office premiums brought by mainland visitors reached HK$ 22.3 billion, down 26.6% in the same period.

Of course, there is a reason for the tightening of regulatory policies. 20 16 The China Insurance Regulatory Commission issued a risk warning about mainland residents going to Hong Kong to buy insurance, reminding everyone to pay attention to risks from five aspects: law, exchange rate, income, service and culture. On June 5438+ 10 of the same year, UnionPay issued the Compliance Guidelines for Overseas Insurance Merchants to Accept Domestic UnionPay Cards, stipulating that domestic residents can use UnionPay cards overseas to pay current account insurance related to accidents, diseases and other tourism consumption, with a maximum limit of $5,000. It is forbidden to use UnionPay cards to pay for other insurance items, which makes it inconvenient to purchase large insurance policies.

In addition to payment, SAFE also stipulates that funds related to overseas insurance (except for a few cases such as travel accident insurance) cannot be withdrawn by cheque payment or wire transfer. Individuals buying life insurance abroad and investing in dividend insurance belong to financial and capital transactions.

The regulations of the State Administration of Foreign Exchange directly make surrender and claim settlement very troublesome. Most insurance companies in Hong Kong still pay by cheque when settling claims or surrendering insurance, but this kind of insurance cheque cannot be cashed in mainland banks, and customers usually have to open an account in Hong Kong to cash it.

However, the "wall" between insurance in the two places is being demolished. 20 17 The HKSAR Government and the China Insurance Regulatory Commission exchanged views on the feasibility of insurance interconnection, hoping to take the construction of Guangdong-Hong Kong-Macao Greater Bay Area as an important opportunity to promote the steady development of insurance cooperation between Guangdong, Hong Kong and Macao.

2065438+In June 2008, Zheng, chairman of the Hong Kong Insurance Regulatory Bureau, revealed that he had visited the China Banking Regulatory Commission, the State Administration of Foreign Exchange and the State-owned Assets Supervision and Administration Commission of China in May of the same year, and proposed to the China Banking Regulatory Commission to allow Hong Kong insurance companies to set up insurance service centers. So as to enhance their service capability in the region, facilitate mainland customers to renew their fees and make claims, and get positive response.

2065438+February 2009, Chen Wenhui, Vice Chairman of the China Insurance Regulatory Commission, met with the Commissioner of the Hong Kong Insurance Regulatory Commission, Dr. LEONG Che-jen, and signed the Framework Agreement between the China Insurance Regulatory Commission and the Insurance Regulatory Commission of the Government of the Hong Kong Special Administrative Region on the Equivalent Assessment of the solvency supervision system, which marked that the China Insurance Regulatory Commission officially recognized the status of Hong Kong insurance in the Mainland and opened the first step for Hong Kong insurance to operate in compliance in the Mainland.

Xu Yun hopes that the acceleration of the pace of interoperability can clear the name of Hong Kong insurance, and the pros and cons can be truly understood: "The past growth was still based on some irrationality and blind obedience. In the future, with the establishment of the Hong Kong Insurance Service Center and even the emergence of the more ideal' Baolian', mainland customers will gradually deepen their understanding of Hong Kong insurance, make more rational choices, and be aware of possible risks after purchase. "