Premium for regular health insurance for elderly residents can be as high as Dh15,000 per annum; under the EBP, it's Dh2,500 Image Credit: Istock

Dubai: Dubai residents who have failed to secure mandatory health insurance cover by December 31 will face a fine of Dh500 a month once the deadline comes into effect from January 1 next year, a top Dubai Health Authority official has said.

Phase 3 of the health insurance coverage for dependants, spouses and domestic workers was to end on June 30, 2016, but the deadline was extended. Dubai residents who have a residence visa coming up for renewal in January and who do not have health insurance will be charged with retrospective effect, from June 30 onwards until the visa renewal date.

Dr Haidar Al Yousuf, director of health funding and the architect of the mandatory health insurance blueprint, told Gulf News: “Our deadline for the last phase remains June 30, 2016, but we did not link it to the visa renewal process, providing people a grace period. However, those who failed to get the cover by the end of this year will be charged a penalty.”

So far, over 3.5 million Dubai residents, including Emiratis and expatriates, have been insured. Of the four million population, only a minuscule percentage of the population remains to be covered. They need to get the cover to avoid any penalties, cautioned Dr Al Yousuf.

In an interview with Gulf News, Dr Al Yousuf sought to clear basic doubts about the law and re-educate the end user about the system of checks and balances in place to tackle the teething challenges which he hopes will be cleared once the system settles in.

1) Residents are confusing the Third Party Administrator for the insurance company. What is the difference?

The insurance company is a corporate company that draws up a contract between itself and the end user providing certain health services for a fee. However, it can outsource certain operations like claims processing to the Third Party Administrator (TPA).

The TPA is a company that delivers the services that an insurance company provides. In other words, all the insurance claims made by the consumer are processed by the TPA. So, if an individual has drawn up an agreement with an insurance company to get a coverage at a certain hospital or clinic, the TPA makes it possible for such a service to be dispensed to the insurance holder.

2. Can you elaborate?

On the DHA website, www.isahd.ae, you will come across a list of 50 insurance companies that provide health insurance choices at different rates. Of these, nine insurance companies have been approved to dispense the Essential Basic Package (EBP) to the common man going for the lowest priced insurance. It is meant for dependants and also covers all those who have a salary of less than Dh4,000 per month.

3. How does an individual shopping for EBP cover for his dependants shop for the best package?

The DHA website, www.isahd.ae, has a comprehensive list of all 50 registered insurance providers in UAE. We have a section called the marketplace on the website where you can compare the benefits against the fee and shop for the best cover.

4. What does the essential health cover package cover?

The basic cover includes outpatient consultancy at clinics, referrals to specialist and for surgical and pathology investigations, maternity health cover, emergency visit to hospital and any surgery required as well as medications. While employers have group insurance schemes for their employees, a resident can shop for a tailor-made cover for his dependants that include spouse, minors and domestic house help.

5. A working woman can get coverage for future pregnancy under the EBP. Why cannot she avail maternity benefit under the EBP if she happened to be pregnant before getting the health coverage?

By its very nature, health insurance is a protection or cover for future conditions or illnesses. So, even if a woman falls pregnant one day after getting the insurance, she has to be covered.

6. What is the maximum coverage an EBP holder can expect?

The beneficiary with basic insurance cover gets a maximum coverage of up to Dh150,000 which is in cases where he requires prolonged hospitalisation.

7. What is the winning feature of the EBP?

The basic insurance covers all those earning under Dh4,000 and is a community-rated product, that means no matter what their age or condition, they will pay the premium approved by the DHA.

8. What is the special protection package provided for the EBP holder?

The special protection package mandates that although a beneficiary has to pay a minimum of 20 per cent of co-insurance payment in case of a hospital stay or surgery, this is capped at Dh500. So, if someone has major surgery amounting to Dh40,000, even those in the basic package would be expected to pay Dh8,000 as 20 per cent. But the protection package mandates a ceiling of Dh500. We have put a cap of Dh500 or a maximum payment of Dh1,000 in the whole year. This protects the interests of the beneficiaries.

9. What does co-insurance mean?

Co-Insurance is the percentage of the bill that the insurance holder has to bear. In the basic package, this has been fixed at 20 per cent. So, for instance, the holder visits a doctor and ends up with a bill of Dh100, he will have to pay Dh20.

10. We have had a reader complain that he was turned away from a government hospital (on the insurance issue).

In the basic package, the first line of defence is the General Physician (GP) who is a kind of a gatekeeper to implement a system of checks and balances to avoid misuse of the scheme. The insurance holder must visit a GP who, after examination, can recommend hospital admission. But direct hospital coverage is available only in case of an emergency. So, if an EBP holder has a health issue, he must go to a clinic that is on the network list covered by his insurance.

Every insurance holder gets this booklet. If the GP feels the individual requires hospitalisation, he will make the recommendation based on which he will be admitted. One must remember the insurance system is trying to achieve a critical balance between access to health care and the cost to economy and, therefore, it is important to assess which cases require acute care.

11. Another EBP holder complained that his physician refused to cover diabetes under the insurance. Why?

A: it is clearly stated that in the case of the essential health benefit package all those who are coming under its purview for the first time cannot get coverage for pre-existing illnesses for the first six months. But if you have a chronic condition that you have declared, it will be mandatorily covered after six months. All declared chronic illnesses will be mandatorily covered even when the holder transfers to another insurance provider. In this case, the patient may have been denied treatment for diabetes as it must be within the first six months and this must be the first instance of him getting health coverage.

12. What should an insurance holder do in case he wishes to lodge a complaint?

The common man holding EPB is encouraged to lodge a complaint about any malpractice or issue he may have with insurance on iPROMes which is part of the www.Isahd.ae website. Our resolution time for a complaint is less than four working days. We do receive about 3,000 complaints per year. Considering that 3.5 million Dubai residents are covered, this is not even 0.0001 per cent of dissatisfied people.

13. Some insurance holders complain that while the insurance successfully covered their treatment for diabetes, when they contracted influenza, they were asked to pay for medicines. Shouldn’t insurance holders be explained what is the maximum limit on medicines in a year?

In EPB, there is a limit for medicines, usually to the tune of Dh1,500. In case an individual has a chronic disease like diabetes or hypertension, usually his medication uses up a substantial part of his annual medicine allocation. So, if he contracts an illness that requires expensive medication, there is a likelihood that he might be asked to cover the cost partly.

One has to understand the people who never had any kind of medicine or health cover are getting access to health care now. However, in some cases, this may not provide 100 per cent cover.

14. Many clinics are complaining that Third Party Administrator (TPA) require approvals at every step as soon as the patient comes to a clinic which causes unnecessary delays. How can DHA minimise this system of approval at every step?

There is no preapproval required to visit a GP in the Essential Basic Package. So, if any TPA is doing that, one can register a complaint. However, once again the system of calling up for approvals is effective in making sure that the cost of health care remains economical and no one misuses the system. It is part of the checks and balances system and all TPAs provide round-the-clock services for approvals which are implemented in no time. One must remember the system is new and is providing health cover to all who were until now paying from their pocket. Under the Essential Basic Package (EBP), they do not need to pay any more but we are making sure that people are not abusing the system.

15. Clinics also complain that many TPAs are holding back their payment to the tune of millions. When clinics do not get reimbursed for their services, they ultimately hold back the facility from the patient. It is the end user who suffers. Why is the DHA not heeding complaints against some TPAs?

Most clinics do complain against TPAs and in a recent drive against non-payment, the DHA was able to release up to Dh7 billion worth of transactions. All clinics are expected to register complaints with us when a TPA repeatedly holds up payments. We take cognisance and the erring company is brought in for a compliance meeting. We issue warnings and also blacklist these companies. Action is taken within 90 days of the complaint. One has to remember the system is new and the cost of health care is very high. The protocols are in place and companies are falling in line.

There will always be some teething problems and initial challenges. Our system, however, has already been recognised internationally to be one of the most smooth and successful roll outs of insurance.