Tuesday, 26 July 2011

Health Insurance - Read Between the Lines

Published in City Times

Health Insurance …What to look for in a cover

Dinesh was certain it would never happen to him or any of his family members. Well, if it did, he felt he would cross the bridge when he got there! But Dinesh woke up to a rude shock when he was diagnosed with a serious health problem which sent his medical expenses skyrocketing. So much so, Dinesh had to dip into his savings to pay his bills! He had no insurance cover!

There are many others like Dinesh who prefer not to think about unexpected catastrophes or illnesses, that always happens to some other unfortunate soul. But, what if you or a family member did have that accident or come down with that serious illness? If you’ve not taken appropriate measures to cover yourself and your family against such unforeseen contingencies, you could be fighting a losing battle with financial crunches compounding your medical problems! For, with escalating health care costs, it is impossible to predict the sum total of your medical bills if you become victim of serious malady or accident.

Dr.S.Surendran Specialist Orthopaedic Surgeon, Welcare Hospital, emphasizes the need for every individual - child and adult - to be covered by insurance. “What I want to emphasize is, think about insurance when you are healthy, not when you become unhealthy. For children, I would strongly recommend insurance cover for the simple reason that they are more vulnerable to fall ill, accidents and injuries. The accidents need not be major – they may be a simple fall in the bath or playground and a few broken bones! Similarly, for chest, gastric and other conditions like dehydration, they might need hospitalization. I don’t mean to say that every child is going to get these, but it’s worth having an insurance cover for them, especially in view of the fact that even simple antibiotics and other drugs are expensive in the region.”

Besides stressing the importance of having insurance cover, Dr.Surendran highlights essential points to be taken into account by individuals and families while seeking such cover. In the first instance, choosing the appropriate coverage is far more complicated than what meets the eye. This is because health insurance policies vary widely and provide coverage for various aspects of health care including physicians’ visits, medicines, investigations, hospitalization, et al.

While some general packages are available, other packages include certain unique features and obviously, the price tags vary accordingly, pretty much widely as well. Emphasizing the quality of health care in the UAE, Dr.Surendran reveals, “It is true that the cost of medical care in this region is slightly dear, but the quality we give is very good. You don’t need to go to the West at all because everything is available here itself. I think most of the people do have an insurance cover which is provided by their employers.”

But herein lies the catch: because organizations provide insurance coverage to their employees, “the employees don’t bother to get a copy of the papers to become well versed with the clauses included or excluded in the policy! The best and first thing that every employee should do is to get these papers from the respective insurance companies or from the Human Resource Department of their respective workplace and go through the legalities of the ‘ifs’ and ‘buts’ of the cover. This is absolutely necessary because there are various grades of cover which each company has. So it is important for every employee to make himself aware of the extent of his cover as per the policy,” emphasizes Dr.Surendran.

Dr.Surendran advices every employee or individual covered by insurance, to check, verify and become fully conversant with every aspect of the policy, particularly those in fine print, which often get ignored. “Firstly, every policy holder or individual who wishes to get insurance cover, should first and most basically look at what he needs from such a cover. The three major areas which need to be covered and which insurance companies offering health cover generally do, are: inpatient treatment, outpatient consultation and pharmaceuticals, that is cover for medications. While most health care providers do cover these three areas, restrictions in terms of ceilings are variously placed, depending on the kind of cover taken. It is therefore very important to check out and ascertain these specifics:
• Is your doctor or hospital, a member of the plan under which you seek cover?
• Should you need to seek consultation with a Specialist, are you covered for it; if yes, what is the amount for which you are covered.
• Is there a co-payment clause featured in your policy? That is, do you have to pay a fraction of the cost of seeking a specialist or service and the rest is paid by the insurance company.
• How many outpatient consultations does your policy allow you within a given period of time?
• Does your plan require you to choose and use a primary care physician? How easy is it to change the physician if you wish to do so at a later date?
• Does it offer complete coverage for hospitalization? Or is there a coverage limit on basic expenses as hospital room, et al?
• Does it provide full coverage for all your family members as well?
• What are the kind of investigations that your policy covers you for? What is the ceiling level on these?
• If surgery is need are you covered for surgical expenses including the surgeons' fees and related costs associated with surgery?
• What is the inpatient cover for elective procedures and for emergencies?
• Does it provide emergency medical evacuation service? That is does it cover cost of air lifting you, say from an accident site, which might make the difference between life and death in some instances?
• What is the ceiling on hospitalization? Apart from room and board, does it cover incidental services costs?
• Does your insurance company give you the facility to upgrade the cover, which obviously will be at a higher premium?
• Do you have to pay if you go outside the network for care?
• Does it cover you only in your current country of residence? Or does it allow you to choose the country in which you wish to receive treatment?
• Does the plan exclude or limit treatment for pre-existing conditions?
• Standard policies may not cover dental problems, eye check ups, mental illnesses, pregnancy, alcohol and dangerous-sports related disorders or injuries. However, should you need cover for these areas, make sure to add them on to.

While taking a health insurance policy, it is important not only to know what is available, but more importantly, policy seekers should know what is NOT available and what are the limits set, emphasizes Dr.Surendran. Even if you are covered by organization as part of its group insurance, it is your right to know the areas you are covered for, with all the set limits. Unless you find out exactly what is, and what isn't covered, you could have a very unpleasant surprise when you need your employer's plan to save the day. If you plan to cover yourself individually, remember that once you choose a health care plan, it is your responsibility to understand the plan and to play by its rules.

No matter which type of health insurance you buy, you have to make sure it offers the right kind of coverage. In addition, apart from the periodic premium that you pay, you need to know if you are required to incur other out-of-pocket costs. This is very important to know since these ‘little’ costs can really add up. Check to see if the health insurance plan requires you to pay any, some or all of the following:

Co-payment: that is, an amount you will have to pay each time you visit a health insurance provider.
Deductible: this is an amount you will have to pay toward your medical expenses before the insurance company begins to pay claims.
Coinsurance: This refers to the percentage of your medical costs you will have to pay after you reach any deductibles that apply.

Dr.Surendran highlights another important aspect with respect to second opinion. “Sometimes, an insurance company itself may send a patient to seek second opinion; else, it is better in certain instances that the patient himself seeks a second opinion. In such cases, it is always better that the patient first speaks to his insurance company to see if he is covered for this – the second opinion.”

Some international companies cover certain things which some of the local insurance companies might not cover. This will be of particular importance to individuals whose job entails a lot of travel. Another aspect which employees need to find out about, is work-related injury, emphasizes Dr.Surendran. “Though most companies would undertake responsibility for this, nevertheless it is in the interests of the individuals, to know well before hand, whether they are covered and the extent of the cover.”

An important factor to bear in mind and make oneself aware of, relates to claims getting denied, cautions Dr.Surendran. “Suppose you’ve had a treatment and despite the doctors’ recommendations, the insurance company does not approve payment or cover fir it, as does happen sometimes, you have the right to find out why you have been denied it. The insurance company is bound to give you an explanation. However, this is where reading the fine print is important. A patient may think he’s been covered while actually he is not!”

What part do doctors and hospitals play in the insurance scenario? The onus of providing good quality care, appropriately, is the cornerstone of treatment as far as the medical fraternity and institutions are concerned. “Hence, as and when required, we give our recommendations to the insurance companies – whether for investigative procedures, be they elective or emergency. Though normally we do get approval for emergencies, they too could be disclaimed by the company. Basically, patients should look at doctors as facilitators who bring your case forward to the insurance company.”


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