Get the facts before buying health cover

There is a common cliché when it comes to health insurance – know your health insurance policy the same way as you know your own health.

Making a little bit of extra effort to stay up-to-date with the terms and conditions of the health insurance plan can not only save one much of the potential hassles that may arise in the future, but can also enable a policy holder to get the best out of his health insurance.

Experts say one of the most viable ways to know the health insurance best is to get rid of a false sense of security. Once the insured is through with it, it's easier for him/her to move ahead to the next step, ie understanding of the plan, for instance, the claims settlement procedure, network of hospitals and clinics the insurer has to offer, the exclusion clauses, etc.

Let's take, for example, the importance of knowing the claims settlement procedure for a medical or health insurance holder, and how to get the best out of it. Normally, insurance companies offer two methods to settle an insurance claim – direct billing and reimbursement.

It is important to know how the insurer settles claims to the member to avail the services covered by the health insurance plans, said Dr Michael Bitzer, CEO, Daman Health Insurance company.

Experts said direct billing facility is normally provided in those hospitals/clinics that have entered into a contract with the insurer.

Go through the insurance document to know whether the hospital/clinic that you visit offers claim settlement on direct billing or reimbursement basis, because some clinics/hospitals might not actually reimburse you 100 per cent of the total medical cost. Instead, they reimburse only 80 or 90 per cent (depending on the contract) as a form of penalty to the patient if he visits any hospital or clinic that falls outside the network of the insurer, said Dr Saif AlJaibeji, Manager, Care Management Programs, Green Crescent Insurance Company, Dubai.

Further, some hospitals/clinics may first ask the patient (who has reimbursement-based plan) to deposit a certain sum, said Dh3,000 or Dh4,000, which not everyone may be carrying every time, especially in times of emergency. Another important point for an insurance plan holder to make sure is the number of days it will take to get the money reimbursed, he said.

The high five

Experts said there are five most important factors an individual must consider when he choose a health insurance policy. These are benefits, exclusions, network, the limit of upfront payment (deductible and co-payment), and lastly the company.

Firstly, a customer wanting to buy a particular insurance product has to look at the benefits or what exactly the policy covers. Secondly, one has to look at what are the exclusions, ie, what the policy does not cover. The third important factor is to know the network or the list of hospitals and clinics where one can have a direct billing access. However, sometimes one can get the same level of benefits and exclusions, but the network may vary, said AlJaibeji.

He said the fourth most important factor is the limit of deductible payment and co-payment or co-insurance that one has to pay. Usually, these two benefits are offered together but different insurance firms offer different deductible amount limit.

Deductible amount is generally the fixed amount that one has to pay whenever the insurance holder visits a doctor for consultation and it usually ranges between Dh25 to Dh50. Co-payment or co-insurance is the percentage of the treatment cost, which one pays (whether as inpatient or outpatient).

For an insurer, co-payment or co-insurance is better than the deductible because the co-payment will limit or reduce the utilisation of the insurance benefits. For a user, on the other hand, a low deductible and low co-insurance policy is better than a plan, which offers a higher deductible or co-insurance payment limit. Therefore, an individual should choose that insurance policy that charges minimum deductible and co-insurance, he said.

Of these two, co-insurance or co-payment is more important than deductible limit because the former can increase with the rise in treatment cost while the latter remains fixed, he said.

The fifth factor, he said, is the insurance company itself.

If you're choosing an insurance policy, don't just go to a company's website or ask people whether a company is good or not. Instead, go and meet firms yourself, he said.

Alternatively, you can ask doctors to check the facilities offered by an insurance company and then assess whether the company is providing solutions that suit them, AlJaibeji adds.

Suitable for employees

Many of the expatriate employees in the UAE and the region get insurance coverage directly from their employers, which in some cases may not be entirely suited to the needs of the employee and so, may not give right services to him. In this case what's the choice left before the employee?

Some employees are lucky to work with companies who listen to their feedback on matters of health insurance and if they believe the policy is not beneficial or suited to their staff, they change the insurer the next year, said AlJaibeji.

However, there are employers who do not listen to complaints of their employees on their insurance policies. Instead, they might be only looking for a cheap insurance plan without assessing whether it's good or not for their employees.

In this case, employees can opt for buying a top-up or a separate insurance, which means they can buy those benefits that are not being covered by the existing insurance policy. But buying a separate individual insurance policy is usually expensive here, and so it's not practical, he said.

However, if an employee has complaint against the insurance company, he should call them first to get clarification on, for instance, why a particular claim was rejected, etc, he said.

Secondly, if the insurance company is not replying to his request or rectifying any mistake, the employee should contact his own company and register his complaint to the human resources department.

If the HR department is co-operative, they will contact the insurance company and pursue the matter, he said.

CLARIFICATION

Further to a story on insurance appearing on Page 40 in the March 23 edition, Daman would like to clarify that their Abu Dhabi plan offers 100 per cent coverage for cost of healthcare services rendered at any healthcare provider operating within Daman's network in Abu Dhabi at an annual limit of Dh250,000. It also provides emergency coverage throughout the UAE.

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