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Everyone needs to be reading from the same page when it comes to medical cover. Or it could prove a costly learning curve for the insured. Image Credit: Shutterstock

Dubai: Some UAE residents are finding what they can claim – and can’t claim – from insurers the hard way. Anjana Sunilan is the latest to feel aggrieved.

She had been told verbally and in writing by her TPA (third-party administrator) that all hospital expenses related to her delivery would be covered by the insurer. Even the co-payment charges – typically 10 or 20 per cent of the final bill – were to be waived. (TPAs are the entities responsible for processing claims related to medical insurance, and are the point-of-contact between the insured and insurer.)

As per those conditions, she only needed to pay Dh500 out-of-pocket, and the rest of the expenses, totaling Dh7,500, would be for the insurer to pick up. But it wasn’t how it turned out to be.

Once the delivery was done and it was time for discharge, Anjana was left with paying all of that Dh8,000. “I was informed at the last minute that the insurer had rejected these claims – even though the TPA had assured us otherwise,” said Anjana, who holds a senior management position at family-owned German Gulf Engineering Consultants llc.

“The insurer informed us that they were not told about the pregnancy at the time of the insurance renewal. If that’s the case, why didn’t the TPA make that clear?

“It’s never a pleasant experience to be told to foot the whole of the hospital bills just before you are getting discharged. If I was at fault for not mentioning the pregnancy during policy renewal time, then what was the TPA doing?”

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Not isolated

There lies much of the problem, and Anjana isn’t the only one to have suffered as a consequence. Insurance industry sources say that TPAs are “promising” more than what they can deliver… or what insurers will allow.

Gulf News spoke to multiple sources who incurred similar experiences with their claims. “The problem is a live one in the local medical insurance space,” said one. “The authorities need to look into this – or the insurers must deal directly with the insured.”

Anjana Sunilan
Anjana Sunilan was expressly told by her TPA that the full pregnancy costs would be borne. But her insurer had a different view on the subject. Image Credit: Supplied

Excessive zeal

Avinash Babur, who heads the portal, says this is an outcome of intensified competition among TPAs to secure policies or renewals, whether individual or corporate.

“TPAs are supposed to be outsourced claims departments for insurance companies,” said Babur. “However they seem to be much more involved in the health insurance value chain as distributors, payment processors (from policyholders), and reinsurance arrangers.

“TPAs seem to be underwriting and even taking on risks that may not be permitted by the regulations. This often creates confusion for clients - and even insurers - in the selling or servicing of health insurance.”

car insurance dubai with
Avinash Babur of reckons that TPAs are taking on tasks over and above what they are mandated to. This leads to giving promises that end up by the wayside. Image Credit: Supplied

Report everything... right out

But insurance industry sources say that more often than not it’s oversight on the part of the insured that leads to unfortunate circumstances where their claims end up rejected.

As with pre-existing conditions, such as diabetes or heart ailments, pregnancy too must be recorded at the time of a claim, whether new or being renewed.

“With health insurance, all disclosures are a must and it is on utmost faith that client must say all before taking cover,” said Leena Parwani, CEO of LPH Financial Services. “An insurance company can't check if the insured does not disclose - but they eventually come to know as soon as the client starts using insurance for pre-existing illnesses or pregnancy… and that's where claims get rejected.

“Corporate group insurance will also need major disclosures these days, because if anyone in a group is having critical illness or chronic conditions, the premium get impacted based on disclosure.”

Premium worries

That’s a point insurance companies – and TPAs - keep bringing up. That if there are pre-existing conditions, it will inevitably raise the premium for that coverage period.

“Before strict mandates were issued by the health authorities in Dubai and Abu Dhabi, insurers used to just provide cover with any pre-existing condition excluded,” said Babur. “Now, they can't do that - they can load the premium but they have to cover it.

"Though with some exceptions, such as new entrants into the country having to go through a six-month waiting period. And of course, all conditions should be declared prior to taking up the health insurance.

“Many clients do not disclose by fear of loaded premiums. Typically, if a small group, a family or an individual is to be insured, pre-existing conditions need to be declared. And this includes any ongoing pregnancies.

“On receiving this information, insurers may load the premiums up to cover their additional potential costs."

Leena Parwani
Leena Parwani if LPH Financial Services is succinct on what needs to be done - the insured will need to front up on any pre-existing conditions they have. The same applies to pregnancy at the time of policy being issued or renewed Image Credit: Supplied

According to Parwani, this comes with the territory. “It is unfortunate that health insurance is expensive because the cost of treatment itself is expansive here,” she added. “But there can be no free lunch…”

Certainly not given by an insurer. As Anjana found out to her cost, all Dh8,000 of it.