Health insurance: How well are you covered?

Every employee who is availing a group health insurance policy in the organisation must demand to read the Table of Benefits (TOB) for his coverage.

- Dr Sanjay Paithankar, Managing Director for Right Health Clinics

The mandatory health insurance is now in its fifth year of a successful roll-out and it is critical that people learn to understand what the benefits of the insurance package are, and how to read the fine print.

As a starting point, it is important for those who are employed to get thoroughly versed with their individual insurance plan and for that they must read it thoroughly, says Dr Sanjay Paithankar, founder of Third Party Administrator Global Net and Managing Director for Right Health Clinics.

“Every employee who is availing a group health insurance policy in the organisation must demand to read the Table of Benefits (TOB) for his coverage,” he says. “This is a summary of the health plan the insurance is providing with all the benefits. Employees can demand to also have a look at the complete plan their company as the main policy holder has signed up for.

Health insurance is important as it provides a basic health cover for the vast majority of people in the emirate.

- Dr Haidar Al Yousuf, managing director of Al Futtaim Health

“This will provide them with a comprehensive idea of the coverage, the network of clinics they can go to, the sub-limits of cost and personal contribution of cost, etc, helping them get educated on the full scope of the health coverage and make optimal use of their insurance.”

10 basic facts that you need to know about your health insurance

1) Coverage:

The Dubai Health Law No 11 stipulates mandatory health insurance for all. This means, every single resident will have to be covered for health insurance. Every health insurance package has a range of coverage which refers to the list of health conditions and health care services that will be addressed.

At the very basic level of coverage is the Essential Basic Package, a health insurance cover that comes at the minimum premium so it is affordable.

What is the premium for EBP? It ranges between Dh550-750 per annum to be paid by the employee sponsor.

What does this coverage include? It could include General Physician consultation, dental and maternity cover, features that are usually covered in the basic package.

This EBP cover also provides a maximum insurance limit of Dh150,000 per annum in case of emergencies.

All pre-existing conditions are also covered in the EBP package after six months from the first time you buy insurance.

“The annual premium amount for EBP has not gone up in the last three years since mandatory health insurance law came into effect. It indicates that insurance for the masses is working in general to provide healthcare delivery to all,” said Dr Al Yousuf.

2) Network:

A network is the organisation contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates. The network provider organises a group of clinics, diagnostic centres and pharmacies to which an individual subscribing to a plan falling under it can go to. This, in other words, means the full list of clinics and hospitals that your insurance package gives you access to. This is also known as an in-network provider.

An out-of-network provider is not contracted with the health insurance plan. On your insurance card, the name of the network is mentioned under the subhead Insurance Provider (IP) net. The policy holder can look up the list of the medical care outlets that he can avail of in the annexure that is provided by the insurance company. Additionally, the TOB provided by the insurance company also includes the list of family health physicians, diagnostic centres and pharmacies that are approved under the EBP. Hospital visits in EBP come on the recommendation of the family doctor.

It’s mandatory by law to have adequate geographic coverage of EBP network all over the UAE, however, one can look at the list and see if the network includes clinics they prefer to use or which are located near their home.

All EBP insurance provides for free emergency treatment at any hospital and maternity cover is also provided.

3) Group v/s individual insurances:

Most people employed in a company can avail of a group insurance which has group discounts. Individual insurances usually are tailor-made and have higher annual premiums depending on the health of the policy holder.

4) Deductibles:

These are sums that have to be borne personally by the insurance holder. There is a basic amount an individual has to pay for consultation at the clinic. For instance, if a doctor’s consultation fee is Dh100, and the deductible is fixed at 10 per cent, the insurance holder will have to pay Dh10 as his portion of the financial contribution.

5) Co Insurance:

Also abbreviated to the acronym COINS on the health insurance card, which refers to the percentage you have to pay from your pocket towards the total bill. The co-insurance is upto 20 per cent of the total bill. So, for example, if you incur a total bill of Dh200 on X-rays, blood test, CT imaging and medicines on a visit to the clinic, if your coinsurance is set at 20 per cent, you would be paying an amount of Dh40 from your pocket.

There are separate limits for outpatient and inpatient coinsurance percentages. Usually in the EBP cover, outpatient coverage — which means a visit to a family clinic for a cough, cold, fever or even a maternity consultation — would be 20 per cent of the total consultation bill.

In the case of a hospital visit for a surgical procedure, the co-insurance could be 20 per cent of the total bill. Check your insurance card for inpatient and out patient coinsurance percentages to know how much you would have to pay per visit.

However, the DHA has put a ceiling on this amount. So, if a patient has to undergo a surgery worth Dh40,000, he will have a ceiling of not more than Dh500 as inpatient coinsurance per episode. A patient can avail of this facility three times in a year, not exceeding Dh1,000 in one year as coinsurance for any inpatient visits.

6) Pharmacy limits:

Each policy sets a limit for the expenses you can make at the pharmacy which in a EBP is usually Dh2,000 per annum. Beyond that sum, the expenses incurred will have to be paid from your pocket. For instance, if you have hypertension or diabetes or both and every two months you incur an expense of Dh400 on your insurance for medicines, in 12 months, you will have visited the pharmacy six times and incurred a bill of Dh2,400. So you would have exceeded your pharmacy expense limits which means you would have to pay Dh400 from your pocket.

The policy holder needs to read the Table of Benefits (ToB) carefully. It also means that in case of a sickness episode which is over and above these number of visits, the policy holder will have to pay from their pocket for the medicines, if he has exhausted the Dh2,000 limit.

Dr Yousuf explains: “One must look at this positively as the resident is covered for a majority of his medical expenses which was not the case earlier, before the insurance became mandatory. Now, he needs to foot the bill for a small percentage of his total medicine requirements.”

7) Pre-Approvals:

Despite the limits, many insurance providers prefer that the clinic seeks a prior approval for particularly expensive diagnostic tests and procedures. This is done to make sure clinics are not over-prescribing these tests. Once the pre-approval is in place, there is no chance of the claim being rejected. In case of an emergency of course, the patient can walk into the nearest hospital, where no questions are asked and immediate treatment is extended. All hospitals in Dubai are bound by law to attend to a patient in emergency where the coverage of the insurance card is not an issue.

8) Pre-existing conditions:

This is relevant only to a first-time subscriber of a health insurance package. In case an individual suffers from any condition such as diabetes, hypertension, cancer or any other ailment, he or she must disclose this at the outset to the insurance company. The condition will not be covered for the first six months after which the insurance will cover it.

What if a person changes jobs or opts into another insurance plan? Will this alter the insurance policy parameters in any way? No. All pre-existing conditions have to be treated under the EBP.

9) Reimbursements:

Usually all EBPs have a direct billing arrangement where the clinics claim the total treatment cost from the insurance provider. However, in many cases, your insurance might allow for an ‘out of network’ consultation or treatment where you pay the cost of treatment upfront and later file a claim with the bills and get reimbursed. Read the fine print on the ToB to know whether you can go to clinics and hospitals that are not in the network of your policy.

10) Last month coverage:

There are instances when insurance policy holder is denied coverage in the last month – such as medicine coverage in the month of December even though the coverage is up to end of that month. This is illegal according to the UAE law.

“If any pharmacy or clinic is doing that, it was illegal,” says Dr Al Yousuf. “The clinic must provide the insurance cover until the last day of the health coverage and insurance policy holders have a right to register a complaint if there is a violation of this right.”

Residents can register complaints on http://ipromes.eclaimlink.ae which is usually attended to within 48 hours of the receipt of the application.

How to read your insurance card?

The tiny plastic card that you carry in your wallet is your gateway to getting health coverage in the UAE. It is therefore important to understand what the subheads and abbreviations there mean.

Your health insurance: what you need to know

Karan Rekhi, Vice President - Operations of Emirates Hospital Day Surgery & Medical Centre, Motorcity, attempts to clear a lot of misconceptions that patients have about their health insurance coverage.

Myth: If I am sick, there is no limit to the number of times I can visit my GP.

Reality: There is a limit to the number of times a patient can visit a doctor for a single episode. Let’s say when a patient discovers he has a fever, or any ailment where he consults a physician at the clinic, he can visit the same doctor for the same episode usually three times within 10 days for the same ailment. So on day one he goes for the first consultation, day three he might report for a follow-up and day six or seven he might want to reconsult to chart his recovery. He will be charged one time consultation fee for this. Once this limit has been reached, further approval from the insurance company must be sought.

Myth: While applying for a pre-approval for a medical procedure, once my insurance company has approved the treatment, I can choose to go for it at any time.

Reality: Approval is only valid for a limited period of time. The exact period of validity should be communicated clearly to the patient. If the patient does not have the treatment within the specified time period, he or she may need to reapply for approval. Besides, patients must know that approvals for tests and procedures take time. For example, if a patient is prescribed tests worth Dh1,500 and his insurance provides cover for only an amount up to Dh1,000, both the patient and the doctor must wait for approval unless it is an emergency.

Only in the case of an emergency should the patient receive treatment for their immediate needs. The hospital or clinic should try to get a response from the insurance company as quickly as possible.

Myth: Since I am insured, my insurance companies will cover all tests.

Reality: Insurance companies may not cover all tests, (for instance tests like Vitamin D tests and screening for HIV or Hepatitis B and C are not covered usually and you need to check your insurance policy plan. A lot depends on the kind of insurance policy the patient has signed up for. Most don’t cover opthalmology and dental treatments and this should be communicated clearly to the patient.

Myth: Insurance companies cover ambulance services.

Reality: Ambulance service is only covered if there is an emergency. The insurance company should ensure that the patient understands this.

Myth: My doctor understands my coverage perfectly and will explain it to me during consultation.

Reality: Doctors do not always know which conditions are covered by a specific insurance policy, so it can be difficult for doctors to prescribe treatments or procedures. The best thing a patient can do is to get their clinic or hospital to call up the insurance company and check against the coverage if the prescribed procedure will be covered.