Dubai: Has it ever happened to you that you got tests and treatments written by a doctor, only to find out that it wasn’t covered in your health insurance plan?
To know why a request may get rejected, it is important to understand how health insurance policies work and how some treatments may be excluded from coverage.
Is it clinically required?
Dr Nayeem Mohammad Abdul, Divisional Director – claims and employee benefits at BMS Masaood Insurance Brokers, spoke to Gulf News to explain the basic principle that is followed by insurance providers when an insurance claim is filed.
“Unless and until there is a visible clinical presentation linked to the test or treatment, it may get rejected by insurance,” he said.
He further explained how the regulatory policies in the UAE are robust and have been designed to ensure patient rights, while stopping abuse of policies due to unnecessary tests and treatments.
He advised people to exercise prudence when it comes to using the health insurance policy: “The regulatory guidelines that have been set by the government are comprehensive enough to take care of the wellbeing of policy holders. My request, however, would be to use it in times of distress and not abuse the policy and consider it like a credit card more than an insurance policy. I say this because there are cases of misuse of the policy, where people end up getting unnecessary treatments and tests. Unfortunately, you will then face a backlash as well, because the premium for the next year’s policy will be higher.”
The regulatory guidelines that have been set by the government are comprehensive enough to take care of the wellbeing of policy holders.
What is an ‘exclusion’?
Another important term to understand is ‘exclusions’, which are treatments and medicines that are not covered as part of your health insurance policy. Whenever you apply for a health insurance policy, a list of these exclusions will be part of the documents that you receive.
Some common exclusions include non-medical cosmetology, obesity-related treatment and fertility treatments.
Basic health insurance plans
According to Dr Nayeem, the majority of policies that are issued fall under the Basic Benefits Plan (which is for those earning up to Dh4,000 per month). Some standard exclusions of this plan are:
1. Healthcare services which are not medically necessary.
2. All expenses relating to dental treatment, dental prosthesis and orthodontic treatments.
3. Surgical and non-surgical treatment for obesity (including morbid obesity), and any other weight control programs, services, or supplies.
4. Medical services utilised for the sake of research, medically non-approved experiments, investigations, and pharmacological weight reduction regimens.
5. Healthcare Services that are not performed by authorised healthcare service providers.
6. Healthcare services and associated expenses for the treatment of alopecia, baldness, hair falling, dandruff or wigs.
7. Health services and supplies for smoking cessation programs and the treatment of nicotine addiction.
8. External prosthetic devices and medical equipment.
9. Treatments and services arising as a result of professional sports activities, including but not limited to, any form of aerial flight, any kind of power-vehicle race, water sports, horse riding activities, mountaineering activities, violent sports such as judo, boxing, and wrestling, bungee jumping and any other professional sports activities.
10. Growth hormone therapy unless medically necessary.
11. Costs associated with hearing tests, prosthetic devices or hearing and vision aids.
12. Allergy testing and desensitisation (except testing for allergy towards medications and supplies used in treatment); any physical, psychiatric or psychological examinations or investigations during these examinations.
13. All healthcare services and treatments for in-vitro fertilisation (IVF), embryo transfer; ovum and sperms transfer.
14. Elective diagnostic services and medical treatment for correction of vision.
15. Nasal septum deviation and nasal concha resection.
NOTE: These are some of the exclusions in the basic benefits plan and may not be excluded if you opt for a higher premium policy, like an Enhanced Basic Benefits Plan. It is important to read the standard exclusions that are applicable to your policy by reaching out to your service provider.
Other reasons why treatments and tests may get rejected
Dr Abdul Wasay, an expert in medical claims who has worked in the UAE for over 10 years in the insurance industry, also spoke about other reasons why your claim may get rejected.
“Generally, we go as per the exclusions of the policy that are governed by the respective health regulator applicable to the emirate, which dictates how your policy is covered but the most important type of rejection that is most frequently encountered is based on ‘medical necessity’. For example, cosmetic procedures. If somebody wants to get a nasal septum correction done, while it is possible that they have some symptoms, like sneezing, that does not require a surgical correction of the nasal septum. Most of the population who have a problem with rejection come under this category of 'medical necessity',” he said.
“If a rejection happens due to this reason, you can simply go back to the doctor and tell them that the treatment has been rejected by the insurance provider. Is it medically necessary? If it is, then give them the reasons as to why it is medically necessary. Otherwise, the doctor needs to advise other treatments that can be done,” he added.
The type of rejection that is most frequently encountered is based on ‘medical necessity’. For example, cosmetic procedures. If somebody wants to get a nasal septum correction done, while it is possible that they have some symptoms, like sneezing, that does not require a surgical correction of the nasal septum. Most of the population who have a problem with rejection come under this category.
Incorrect or incomplete documentation
Another reason why applications may get rejected is that the documentation, as well as the ‘coding’ put in with the request was incorrect. With every type of treatment and test having a relevant code, it is important for your hospital or clinic to put in the request under the right code. If it does get rejected due to this reason, you can simply follow up with your doctor to investigate and try to find a solution for it.
Undisclosed conditions
Finally, a treatment may also get rejected because it is due to a pre-existing conditions which was not disclosed at the time of taking the policy. This is why it is important to provide honest and accurate information when enrolling for a policy.
How to best use your policy
Dr Abdul Wasay also provided some tips for readers, which can help them get the best out of their policy:
1. Try to get a second opinion, especially when it comes to elective procedures. This is beneficial for patients as well, as they protect themselves from procedures that may not be medically necessary.
2. Try to always get the first treatment from a primary healthcare provider, which is a General Practitioner (GP). In case a specialist is required, the GP will be able to refer you to the right specialist, stopping you from unnecessary ‘specialist hopping’.
3. If you are going for an out-patient consultation and treatment, opt for clinics instead of hospitals. While there is a cost difference as well, this also protects you from exposure to more infections.
4. Be mindful of your healthcare spending, as unnecessary usage can lead to inflation of premiums in the following year, or reduction of benefits.
