Insurance Claim Denied in Hong Kong: How to Appeal via OIC

Hong Kong is home to one of Asia's largest insurance markets, with hundreds of licensed insurers and tens of thousands of policyholders making claims every year. When a claim is denied, policyholders have a regulatory framework and a free complaints process available to them — but many don't know how to use it.

This guide explains your rights under Hong Kong insurance law, how to file an effective appeal, and how to use the Insurance Authority (IA) and the Office of the Insurance Claims Complaints Bureau (ICCB) — now absorbed into the IA's resolution framework — to challenge an unfair denial.

The Hong Kong Insurance Regulatory Landscape

Insurance in Hong Kong is regulated by the Insurance Authority (IA) under the Insurance Ordinance (Cap. 41). The IA licenses all insurers operating in Hong Kong and sets the regulatory standards they must meet.

For dispute resolution, the key body is the Insurance Claims Complaints Bureau (ICCB), which was established in 1990 and continues to operate under IA oversight. The ICCB handles consumer complaints about insurance claims through a mediation and adjudication process.

Additionally, the Voluntary Health Insurance Scheme (VHIS) — introduced by the Hong Kong government in 2019 to make private hospital coverage more transparent and portable — has specific dispute mechanisms of its own.

Common Reasons Insurance Claims Are Denied in Hong Kong

Life and health insurance:

• Non-disclosure of material facts at application (the most common ground)
• Pre-existing conditions not listed on the application
• Dispute over whether a condition requires hospitalisation
• Treatment classified as not medically necessary
• Benefit limits exceeded (per visit, annual, or lifetime)
• Hospital not covered under the policy's approved facilities
• Claims filed outside the prescribed timeframe

VHIS-specific denials:

• Treatment not falling within the VHIS standard or flexi plan benefits
• Psychiatrist or specialist not on the approved list
• Waiting period disputes (12 months for most conditions)
• Claim amount exceeding prescribed benefit amounts

Motor insurance:

• Driver not named on the policy
• Accident not reported to police within required period
• Driving without a valid licence
• Vehicle used for purposes beyond the policy scope

Travel insurance:

• Pre-existing medical condition
• Activity excluded from the policy
• Claims not supported by required documentation (medical receipts, police reports)

Your Rights Under Hong Kong Insurance Law

The Insurance Ordinance (Cap. 41) and the IA's regulatory requirements give you the following rights:

• Right to a written explanation: Insurers must explain claim decisions clearly and in writing.
• Right to appeal internally: Your insurer must have an internal complaints process.
• Right to ICCB mediation: If the internal process fails, you can use the ICCB process free of charge.
• Right to IA escalation: Regulatory complaints can be filed with the IA.

The IA has also issued Guideline on Underwriting Long Term Insurance Business (Other than Class C Business) which sets out fair practices for claims handling.

Non-disclosure and the contra proferentem principle: Under Hong Kong common law, ambiguous insurance contract terms are interpreted against the party who drafted them — the insurer. This is the doctrine of contra proferentem, and it can be a powerful tool in disputes where the policy wording is unclear.

Step-by-Step: How to Appeal a Denied Claim in Hong Kong

Step 1: Get the Denial in Full Writing

If you received a verbal denial or a brief letter, write to the insurer immediately requesting:

• The full written reasons for the denial
• The specific policy clause(s) being applied
• Any medical reports or assessments conducted by or for the insurer

In Hong Kong's insurance culture, initial denials are sometimes issued without full explanation. Demanding a complete written explanation is your first power move.

Step 2: Review Your Policy and Application Documents

Pull out your original policy document and application form. Check:

• Whether the exclusion being cited is clearly stated in the policy
• Whether any conditions or facts you're accused of non-disclosing were actually asked about in your application
• Whether any condition pre-dated the policy or arose after inception

If you didn't disclose a condition because you weren't asked about it, or because you genuinely didn't know about it, this is a defence under Hong Kong law.

Step 3: Compile Medical Evidence

Get your treating doctor or specialist to provide:

• A detailed clinical letter confirming the diagnosis and when it first manifested
• A statement on whether the condition pre-dated the policy
• Clinical evidence supporting the necessity of the treatment

For VHIS claims, also obtain confirmation from your hospital that it is a VHIS-approved facility and that the treatment falls within VHIS benefit categories.

Step 4: Lodge a Formal Internal Complaint

Write a formal complaint letter to the insurer's complaints department. Include:

• Full contact details and policy number
• A clear statement of dispute
• Your grounds for challenging the denial
• Your evidence bundle (numbered and indexed)
• A request for a written response within 21 days

Most major Hong Kong insurers have an English-language complaints process. If your insurer is smaller or primarily operates in Chinese, be clear that you require a bilingual response if needed.

Step 5: Escalate to the ICCB / IA

If your internal complaint is not resolved satisfactorily, escalate to the Insurance Claims Complaints Bureau (ICCB).

How to file with the ICCB:

1. Download and complete the ICCB complaint form from the IA's website at ia.org.hk
2. Attach all relevant documents (policy, denial letter, internal complaint and response, evidence bundle)
3. Submit to the ICCB

The ICCB process:

• Mediation: The ICCB will contact your insurer and attempt to mediate a settlement
• Adjudication: If mediation fails, the complaint is referred to an Adjudication Panel of independent professionals (legal, medical, or insurance experts as appropriate)
• Award: The Panel can make a binding award against the insurer up to HKD 800,000

The service is free for policyholders. The entire process typically takes 3 to 6 months.

Step 6: File a Regulatory Complaint with the IA

For complaints about insurer conduct (unreasonable delays, failure to respond, deceptive practices), file a complaint with the Insurance Authority directly at ia.org.hk/en/consumer-corner/complaint.html.

The IA focuses on regulatory compliance rather than individual dispute resolution, but IA complaints can prompt regulatory review of insurer practices and may apply pressure to resolve your individual case.

VHIS: Special Considerations

The Voluntary Health Insurance Scheme was designed to give Hong Kong residents more confidence in private health coverage. VHIS products must meet minimum standards set by the Food and Health Bureau and are certified by the Hong Kong government.

VHIS protections include:

• Guaranteed renewal: Insurers cannot refuse to renew your VHIS policy
• No cancellation for health status: Insurers cannot cancel your policy because of health changes
• Portable coverage: Coverage follows you when you change employers
• Transparency: Standard benefit amounts are publicly listed

VHIS dispute resolution follows the same ICCB process. However, if an insurer is refusing to honour a VHIS benefit that is clearly described in the government's standard benefit schedule, this is a particularly strong complaint — you can reference the government-published schedule directly.

Non-Disclosure: What the Law Actually Says

Many Hong Kong insurers deny claims by citing non-disclosure. However, under Hong Kong insurance law, the insurer must prove:

1. The undisclosed fact was material — meaning it would have influenced a prudent insurer's decision to accept the risk or set the premium
2. The non-disclosure was either deliberate, or the applicant knew or should have known the fact was material

If a condition wasn't specifically asked about in the application, or if you had no reason to know about the condition at the time of application, these are strong defences. The ICCB has frequently found against insurers who tried to use minor or unrelated non-disclosures to void an entire policy.

Common Mistakes to Avoid

Not getting everything in writing: Hong Kong's insurance dispute process is document-driven. Phone calls don't count.

Assuming non-disclosure automatically ends your claim: It doesn't. Challenge the materiality and the relatedness of the alleged non-disclosure.

Not checking VHIS certification status: If your policy is VHIS-certified, you have additional government-backed protections. Check the VHIS product list at vhis.gov.hk.

Missing the ICCB time limits: Complaints to the ICCB must generally be made within 2 years of the event giving rise to the dispute.

Accepting a cosmetic exclusion without clinical evidence: If your insurer classifies a procedure as cosmetic, get your surgeon to provide a letter explaining the medical (not cosmetic) indication for the procedure.

Getting Help with Your Appeal

A structured, evidence-backed appeal letter is essential in Hong Kong's insurance complaint culture, where written documentation carries significant weight.

ClaimBack (claimback.app) generates professional appeal letters tailored to Hong Kong insurance law, the specific denial reason, and the ICCB process. The tool is free and helps you frame the right legal and clinical arguments for your specific situation.

Summary

1. Get the full written denial with specific policy clause references
2. Review your application form — what was asked, what was answered
3. Get a specialist clinical letter addressing the denial grounds
4. File a formal internal complaint with a 21-day response deadline
5. Escalate to the ICCB for mediation and adjudication up to HKD 800,000 — free service
6. Use VHIS government-published standards if your policy is VHIS-certified
7. Challenge non-disclosure arguments: materiality and relatedness both matter