Health cover loopholes need vetting: experts

Dubai: Health care in Dubai is about to get a major facelift, with health insurance for all — citizens and residents — becoming mandatory in 2014.

However, health experts are vetting the eventual rollout with great care to see just how the new programme shapes up for all those involved.

It can be a win-win situation for everyone — the Dubai Health Authority (DHA) and Dubai residents — provided stakeholders, such as corporations, insurance companies and medical health service providers all play their parts ethically, says Dr Sanjay Paithankar, Managing Director of Global Net, a third party administrator servicing many insurance networks in the city.

“The real challenge for the DHA will be actually implementing the law in letter and in spirit,” Dr Paithankar says

Only 20 per cent of blue collar workers have health insurance cover and in the higher income groups, about 60-70 per cent are covered, he says.

The new law makes it mandatory for all 3 million people in Dubai (nationals and residents) to have insurance cover. This will be linked to the visa.

“It would be a welcome relief to the government, which is reeling under very high health budgets,” he adds.

Take the case of an 80-year old-expatriate businessman who has lived in Dubai for 30 years and is currently lying in a vegetative state in the ICU of a government hospital for the last year.

His wife, 70, is unable to take care of him. His son, who is not on the father’s company visa and works in the service sector, is unable to meet the expenses.

The government is burdened with his expense as he has no insurance cover and his immediate family members are unable to meet his needs.

The government needs public and private partnership to provide good healthcare to all residents.

Spending

In 2011, the health spending of Dubai and Abu Dhabi put together was Dh36 billion and it is projected that in 2015 health spending is likely to go up to Dh40 billion.

“By getting the employers to provide insurance cover, the government can bring this cost down by 30 per cent and also provide better health care to all people residing in Dubai,” Dr Paithankar says.

Insurance bill will run into millions as employers will have to shell out a minimum annual premium of Dh500 per employee annually and provide an annual cover of Dh150,000 as the DHA is demanding.

This will cover basic health care, pathology examinations, OPDs at clinics at the designated hospitals, clinics and also surgery expenses up to Dh150,000 as per the DHA requirement.

But there are many loopholes that need to be addressed.

What happens at present?

Currently, with an annual premium of Dh400-Dh600, most insurance companies provide a cover of Dh50,000.

This means that if the policy holder get ill or needs an unforeseen surgery, his expenses up to Dh50,000 are taken care of by the insurance provider.

However, most insurance providers have a sub-clause in their policy that in case of chronic or pre-existing condition they will pay only Dh30,000.

In cases of sophisticated pathological investigations they often pay just 50 per cent of the amount.

The remaining or co-insurance amount is to be paid by the insurance policyholder. Then they have an in-patient limit of around Dh25,000 per person per annum.

So if a policyholder experience cardiac pain and is rushed to the hospital, first they have to meet 50 per cent of the sophisticated investigation amount.

So, if their CT Scan and MRI bills runs up to Dh30,000, they have to pay Dh15,000 as per their co-insurance amount.

Then if they establish the heart condition was a pre-existing condition, the insurance would pay only Dh30,000 of the total amount.

In most cases, the basic fee for an ICU is about Dh3,000 per day and the medication, ventilator charges and daily treatment charges are separate.

If the person has been admitted to a hospital, needs surgery and a stay in the ICU and other investigations he can easily run up a bill that goes beyond Dh50,000.

When the time comes to pay up, an insurance provider can cite the fine print and have the policy holder pay more than 40 per cent of the total amount.

Additionally, work related injuries are never covered in a regular insurance policy. For this, every company has a separate insurance coverage.

Dr Paithankar says that it is likely that if insurance companies are asked to provide insurance cover of up to Dh150,000 they will try and manipulate the deductibles and the co-insurance amounts in a manner that will ultimately burden the common man with very high bills, discouraging people from going to a hospital in case of major illness.

Premiums

“Usually when the annual insurance cover goes up, the insurance companies also jack up the premium amount, which can be anything between Dh600-Dh10,000,” he said.

However, the DHA Director of Funding Dr Haidar Al Yousuf in an exclusive interview to Gulf News vowed that they will not let this happen.

“The minimum requirements [premium and annual coverage] will be defined by law and cannot be changed.

“Everything that has been mentioned will be allowed. Special investigations will require pre-authorisation but if a patient needs it, it will be done with a pre-authorisation. No insurance company can shift the burden to the common man.

“Only insurance companies that can provide this basic health benefits with these premiums and the annual health cover can register with us.

“Only those who fulfil DHA criteria will be allowed. We will look at companies that have the ability to manage large portfolios, high numbers, acceptable benefits and less profit.

“There will be other high end insurance companies cat-ering to other kinds of clients. Even they can apply for additional permit to work out a basic package on our criteria.”

Ideal package

Most insurance companies are currently working out the ideal package that can give them a neat profit and also please the common man, a tough tightrope to walk.

How can the average man know what kind of policy has been given to him and what the real benefits are for him?

It is mandatory for all companies who are the policyholders in case of group policies to get a representative from the service provider to come and explain the actual Table of Benefits (ToB).

“What really needs to be examined closely is the ToB that an insurance provider gives. Usually companies have a group policy and the ToB is given to a company’s HR department. Companies need to educate the labourers about their rights.”