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星屑醫生 | 18th Mar 2008, 17:46 PM | 香港的醫療本相

醫生和保險常有衝突,特別是受不過他們所謂政策 保單條款(Policy)的掣肘,深深覺得那是行外人影響行內人的行為,侵犯了醫生的專業自主。

今天就發生一件小事。醫療集團的職員小姐打電話來,說某病人的收條上寫 gingivitis (牙肉發炎),保險公司說不予受保,就想請我改一下,好讓那病人的診治可以受理。

我納罕,牙肉發炎明明是口腔內的細菌感染,和腹腔感染、皮膚感染、上呼吸道感染,耳朵感染,甚至陰道感染、心瓣感染、腸道感染等疾病的原理都並無二致,為甚麼其他的感染都受保,偏偏牙肉就不受保?

我深深不忿,就和職員小姐理論,她自然只會給我最典型的答法:「Policy 是這樣,沒有辦法,你有不滿就請寫封信投訴,你們寫信才有力呀!」

奇就奇在我改了作「口腔感染」,他們又肯受保了。實在牙肉發炎本來就是口腔感染的一種,這樣寫就肯保,好明顯就是制度彊化的產物,而設定制度的人,卻肯定是個醫療的門外漢,對疾病的知識,連一知半解都談不上。

我說:「小姐,若換了你自己牙肉發炎,也勢不會估到來看西醫會不予受保吧」。根本我自己,好多時都會收到來自牙科的轉介,就先由我們處理了病人的牙肉發炎或膿瘡,例如處方抗生素甚至放膿,等情況受控牙醫就會接手診治。反而保險公司竟完全無視我們的運作,一廂情願的硬性規定不予受保。

這是冰山一角,也只屬雞毛蒜皮的小事,然而更多和更嚴重的衝突卻俯拾皆是。醫療融資的其中一個重點是全民醫療保險,不知道決策者又有否想過,醫療保險本身其實存在灰色地帶、有失公平之處和很多漏洞,例如最普遍「預你投保卻不預你 claim 錢」的取向,還有作為行外人對醫療專業的干預等等。到時受害的,還不是小市民?


[12]

"星屑醫生,相信你的病人應該係claim團體醫療保險,團體醫療有好多項目架,有d僱主只會幫僱員買門診同住院,冇買牙科架....希望你能明白到保險公司亦要保障自己架,近年黎,有好多客戶係濫用保險公司的索償架....."
其實近年來也有好多人濫用醫生的專業搵著數,esp保險客...

"保險公司的索償係要講近因關係架,舉個例子丫,有客戶整傷咗,去睇中醫,醫師係張收據寫背痛,然後個客同我地claim意外保險,背痛我地係唔賠架,因為我地有權懷疑個客背痛嘅原因可能係佢坐姿唔好或身理因素影響,並非意外所致,同樣道理,你寫牙肉發炎,我地有權懷疑你個病人嘅病患係同牙科疾病有關架..."
當然你有權懷疑同唔賠償,但呢個係你同病人之間的事,唔應該把賠同唔賠的責任推落醫生度,叫醫生修改diagnosis令唔受理變成受理.你都係專業的...

"其實我地保險公司係保單所列嘅條款,係經過專業人士嘅意見架,唔係制度彊化,係我地要保障自己啫,如果我地唔列得細緻d,濫用索償嘅情況又會多d...
至於你話醫療保險有漏洞,有失公平,有「預投保人投保卻不預投保人 claim 錢」的取向,還有好多行外人對醫療專業的干預....
其實保險公司冇實物賣比人架,我地只係賣個保障比你架,點會唔claim比人呢,"

你係俾人claim, 不過claim唔claim到係另一回事.

"每一年我地全行都會公佈該年賠償嘅情況,保險公司係受好多機構監管架,如果真係唔claim比人,我地一早比人投訴咗,上哂報紙啦...."

君不見三日唔兩日有客因為claim唔到上報紙服務版投訴嗎??


[引用] | 作者 CCTV | 28th Mar 2008 12:37 PM | [舉報垃圾留言]

[11] re: insurance company

Right, entirley agree with you folks. Insurance companies are just there to receive your insurance premium, they are not there to pay you $ after you make any claims. They try every single means to curb you from obtaining reimbursements (compenstations) or whatever that cost them $.
Especially nowadays, insurance representatives are just looking at their commissions + incomes.
If the proposed Mandatory Medical Fund really starts out, then Hongkongers [patients] will walk the same difficult trail of Americans. They pay compulsory medical inusrance, but the medical+therapeutic fees are way way higher than their premiums paid.
Thus, Americans like buying over the counter drugs instead of seeing the doctors unless it's about life and death or long term illness.


[引用] | 作者 Eddy Ho | 25th Mar 2008 18:14 PM | [舉報垃圾留言]

[10]

Insurance companies are not charities! Their very existence is to make money. So they will say "NO" to anything that will eat into their profits. Get real...


[引用] | 作者 er... | 22nd Mar 2008 17:10 PM | [舉報垃圾留言]

[9]

星屑醫生有無睇過 Michael Moore o既 sicko?係講美國o既醫療保險問題

有好多「預你投保卻不預你 claim 錢」o既問題,o的醫療總監o下o下都用o的「個手術仲係實際性質」等理由o黎唔批錢畀你做手術

片中仲比較返加拿大、英國、法國甚至古巴o既醫院都唔使錢,星屑醫生你又點睇呢幾個國家o既醫療制度?

p.s.mandy你又唔使咁大反應,講真,你相信呢個世界全部保險公司都係憑良心做生意?而且o的保險公司全部都諗唔到方法拒絕批錢畀人?一旦有方法,就會有人咁做,難道又唔使提防?


[引用] | 作者 atk | 22nd Mar 2008 15:45 PM | [舉報垃圾留言]

[8] Re: freesky
freesky :
er... :I do not believe in insurance at all. Even my friend, who used to work for Manulife in Canada in their actuarial department advised me AGAINST buying insurance. She believes that since the money that insurance companies pay us come from our own anyway, why don't we save up a portion of our in...

She was referring to HK. I asked her about insurance policy in Hong Kong, after she had left Manulife in Canada and was working in another insurance company in Hong Kong then. Indeed, you do not need to buy insurance at all because OHIP pays for it (if you are in Ontario).


[引用] | 作者 er... | 19th Mar 2008 21:20 PM | [舉報垃圾留言]

[7] Re: mandy
mandy :
星屑醫生,相信你的病人應該係claim團體醫療保險,團體醫療有好多項目架,有d僱主只會幫僱員買門診同住院,冇買牙科架....希望你能明白到保險公司亦要保障自己架,近年黎,有好多客戶係濫用保險公司的索償架.....
保險公司的索償係要講近因關係架,舉個例子丫,有客戶整傷咗,去睇中醫,醫師係張收據寫背痛,然後個客同我地claim意外保險,背痛我地係唔賠架,因為我地有權懷疑個客背痛嘅原因可能係佢坐姿唔好或身理因素影響,並非意外所致,同樣道理,你寫牙肉發炎,我地有權懷疑你個病人嘅病患係同牙科疾病有關架...
其實我地保險公司係保單所列嘅條款,係經過專業人士嘅意見架,唔係制度彊化,係我地要保障自己啫,如...
呀,謝謝你的回覆~ 哈,我這就是拋磚引玉了。
就是要多些有來有往,因為我們都只站在自己的位置發聲,然後不同人球來球往才會得出諒解和共識。

我漸漸也會明白你們的思維。其實我的保險經紀就是我少年時團契的導師,他真的好欏個心出來做,甚至會陪客戶入院出院。

現在因受傷的,我都一定會寫BY ACCIDENT。不過有時這會令我們陷於進退維谷,你知,有些真的好難說是真BY accident 還是因為坐姿問題等原因的。

星屑醫生
[引用] | 作者 星屑醫生 | 19th Mar 2008 09:51 AM | [舉報垃圾留言]

[6] Re: er...
er... :
I do not believe in insurance at all. Even my friend, who used to work for Manulife in Canada in their actuarial department advised me AGAINST buying insurance. She believes that since the money that insurance companies pay us come from our own anyway, why don't we save up a portion of our income ea...

that possibly be ok in Canada, but in the US, there is totally different, especially for long-term disease.
Several years ago, I needed to have MRI of cervial spine caused of my syndrome, my insurance didn't pay for that because they think I required to have MRI for that. Then I called my doctor who asked me to have it, and that doctor called my FM to change the medical code. Then my insurance paid.


[引用] | 作者 freesky | 19th Mar 2008 08:07 AM | [舉報垃圾留言]

[5]

星屑醫生,相信你的病人應該係claim團體醫療保險,團體醫療有好多項目架,有d僱主只會幫僱員買門診同住院,冇買牙科架....希望你能明白到保險公司亦要保障自己架,近年黎,有好多客戶係濫用保險公司的索償架.....
保險公司的索償係要講近因關係架,舉個例子丫,有客戶整傷咗,去睇中醫,醫師係張收據寫背痛,然後個客同我地claim意外保險,背痛我地係唔賠架,因為我地有權懷疑個客背痛嘅原因可能係佢坐姿唔好或身理因素影響,並非意外所致,同樣道理,你寫牙肉發炎,我地有權懷疑你個病人嘅病患係同牙科疾病有關架...
其實我地保險公司係保單所列嘅條款,係經過專業人士嘅意見架,唔係制度彊化,係我地要保障自己啫,如果我地唔列得細緻d,濫用索償嘅情況又會多d...
至於你話醫療保險有漏洞,有失公平,有「預投保人投保卻不預投保人 claim 錢」的取向,還有好多行外人對醫療專業的干預....
其實保險公司冇實物賣比人架,我地只係賣個保障比你架,點會唔claim比人呢,每一年我地全行都會公佈該年賠償嘅情況,保險公司係受好多機構監管架,如果真係唔claim比人,我地一早比人投訴咗,上哂報紙啦....
每一個行業都有其獨特之處,看似獨立,但又會互相緊扣,醫療融資政府會徵詢我地保險業嘅專業意見,同樣,我地係界定保單條款時,我地亦會徵詢醫生嘅專業意見....
我相信世界上冇人或者冇一個團體係識哂所有嘢架,一定多問多學多徵詢先會有成長,先會完善架,世界外還有世界呀,當你以為自己係最專業、最叻嘅時候,可能企係你後面果個比你更叻、更專業。
我唔敢批評你咩,始終我比你年輕,無論人生經驗、視野等都唔會比你廣闊......


[引用] | 作者 mandy | 19th Mar 2008 05:10 AM | [舉報垃圾留言]

[4]

而受益的永遠就是那些保險公司,as a 受保人,我也常常很難明為什麼有d野包,有d野唔包(而兩樣是同一nature既野)
the problem is that insurance policy is deteremined based on risk statistics of what the population needs, not nature of illnesses


[引用] | 作者 ceeweileung | 19th Mar 2008 02:07 AM | [舉報垃圾留言]

[3]

我估policy應該係指保單條款而非政策

另外,出現問題的主因,有時係病人明知有野係唔包
唔想比錢,所以格硬要醫生填一些可以claim到既野...


[引用] | 作者 jason | 19th Mar 2008 00:07 AM | [舉報垃圾留言]

[2]

依家尐人就係咁死古古...
唉~~~


[引用] | 作者 悟樂 | 18th Mar 2008 23:36 PM | [舉報垃圾留言]

[1]

I do not believe in insurance at all. Even my friend, who used to work for Manulife in Canada in their actuarial department advised me AGAINST buying insurance. She believes that since the money that insurance companies pay us come from our own anyway, why don't we save up a portion of our income each month? That way we will be able to use ALL the money, rather than having most of it being paid to insurance companies in the form of administrative and other fees!

I only go to private doctors, even for my surgeries two years ago which cost me a total of 300K+ (including renting of the OT, hospital rooms and doctors' fees, etc.). So even if I contribute to the mandatory medical insurance provided by the government, in co-operation with other (unscrupulous) insurance companies, I will still have to fork out a lot of money to pay for my medical bills!


[引用] | 作者 er... | 18th Mar 2008 20:22 PM | [舉報垃圾留言]