Insurance Law · 15.11.2024

Medical Insurance in Vietnam: What Pays, and When It Does Not

Two different things are called medical insurance in Vietnam, and they fail in different ways. One is the State health insurance scheme. The other is commercial health cover bought from an insurer, which is where refusals, exclusions and disclosure fights happen. This page is abo…

Lawyer UnilawReading time: 6 min

By Lawyer Nguyen Nhu Hai – UniLaw LLC

Two different things are called medical insurance in Vietnam, and they fail in different ways. One is the State health insurance scheme. The other is commercial health cover bought from an insurer, which is where refusals, exclusions and disclosure fights happen. This page is about the second, and about the separate question of who pays when a hospital causes the injury.

Where commercial health cover sits in the statute

Article 7(1) of the Law on Insurance Business No. 08/2022/QH15 recognises three types of insurance: life, health and non-life. Decree No. 46/2023/ND-CP, Article 5, splits the health type into two lines: health and bodily insurance, and medical expenses insurance. Which line your policy was written under decides what it is supposed to pay: a benefit on a defined event, or the cost of treatment actually incurred.

Article 33 confirms that the subject matter of a health insurance contract is the person’s health, and the contract rules in Section 2 of Chapter II apply to life and health contracts together. That matters, because several of the provisions below are drafted for both.

Most refusals are disclosure fights, and the test is deliberate intent

A health claim is usually refused on the proposal form: an undeclared condition, an incomplete answer. Article 22(2) allows the insurer to rescind only where the policyholder deliberately gave incomplete or false information, and did so in order to obtain payment. An honest omission or a careless form does not meet that standard.

Article 22(3) points the other way and is rarely used: where the insurer deliberately withheld information or supplied false information to get the contract signed, the policyholder may rescind, recover the premium, and claim damages.

The exclusion has to be proved, not just printed

Article 19(2) requires the insurer to state exclusions clearly in the contract, to explain them fully, and to hold evidence that the policyholder received that explanation and understood it at the time of contracting. If a refusal rests on a waiting period, a pre-existing condition clause or an excluded treatment, ask in writing for that evidence first.

Article 19(3) removes the late-notification exclusion entirely where force majeure or an objective obstacle caused the delay.

Twenty-one days to walk away

Article 35 gives the policyholder, on any contract with a term over one year, 21 days from receiving the policy to refuse to continue. The contract is then cancelled and the premium refunded less reasonable costs agreed in the policy; the insurer owes nothing for an event in that window. Read the schedule of exclusions inside those 21 days, not after the first claim.

Cases where a health or life policy pays nothing

Article 40(1) lists them: suicide within two years of the first premium or of reinstatement; death caused by the deliberate act of the policyholder or a beneficiary; permanent disability caused by the deliberate act of the insured, the policyholder or a beneficiary; death by execution of a death sentence; and other cases agreed in the policy.

Two qualifications matter. Article 40(2): where there are several beneficiaries and one of them deliberately causes the death or permanent disability, the insurer still pays the others. Article 40(3): in the Article 40(1) cases the insurer must still return the surrender value, or the premiums paid less reasonable costs, and if the policyholder has died that sum passes under the law on inheritance.

The provision worth knowing if a hospital caused the injury

Article 38 is unusual and useful. Where the insured dies, is injured or falls ill through the direct or indirect act of a third party, the insurer must still pay under the policy and has no right of recourse against that third party — and the third party remains liable to the insured under the law.

In practice: a patient with commercial health cover can claim on the policy and still pursue the hospital. The insurer cannot stand in their shoes and take the recovery. This is the opposite of the subrogation rule for property and damage cover in Article 54.

Who pays for a medical incident

Article 102 of the Law on Medical Examination and Treatment No. 15/2023/QH15 places the duty to compensate a patient for a medical incident on the facility, subject to the exceptions in Article 100(2). Not on the individual practitioner.

Article 103 then requires professional liability insurance in medical practice, and defines it as covering both the compensation for damage from a medical incident occurring within the policy period and the legal costs of the claim arising from it. Article 103(2) makes the insurer pay that to the facility under the policy, and Article 103(3) refers the mechanics back to the insurance business law.

So a patient’s claim usually has two payers behind it: their own health cover, and the facility’s liability insurer. Identifying both early changes how the claim is presented.

Deadlines and the route out of a dispute

One year from the insured event to file the claim with the insurer — Article 30(1). Time lost to force majeure or an objective obstacle does not count, and Article 30(2) runs the year from the date the insured or beneficiary learned of the event where they can prove they did not know.
15 days for the insurer to pay where the policy fixes no period, counted from a complete valid file — Article 31(1), with interest on late payment under Article 31(2).
Where cause or extent is disputed, an independent surveyor under Article 53(2), appointed by the court or the arbitral tribunal if the parties cannot agree, whose conclusion binds both, at the insurer’s cost under Article 53(1).
Article 32 sets the sequence: negotiation, then mediation, arbitration or court according to the policy.

What a refused health claim file should contain

The policy, the schedule and the exclusion actually relied on, identified in writing.
The insurer’s Article 19(2) evidence that the exclusion was explained and understood.
The proposal form, with each answer tested against the deliberate-intent standard in Article 22(2).
The date the claim file became complete, for the Article 31 clock.
Where a facility is involved, its professional liability cover under Article 103 of Law No. 15/2023/QH15.

Legal basis cited above: Law on Insurance Business No. 08/2022/QH15, Articles 7, 19, 22, 30, 31, 32, 33, 35, 38, 40, 53 and 54; Decree No. 46/2023/ND-CP, Article 5; Law on Medical Examination and Treatment No. 15/2023/QH15, Articles 100, 102 and 103.

If a health or medical claim has been refused on a disclosure point or an exclusion — see Unilaw’s insurance practice, or call +84 912266811 for a first assessment and a fee quote before any work starts.