Health Insurance Issues

April 13, 2017

Health insurance is a critical component of the Fijian health care system that can take pressure away from the public health system. But for that to happen, it is vital that consumers have the confidence that the insurance policies they purchase will provide them with real value when the need arises.

The purpose of health insurance is to protect consumers financially in the event of any unexpected serious illness or injury that could leave a deep hole in their pocket. Consumers purchase health insurance policies for their peace of mind knowing that they are protected from unforeseen health costs.

It is generally seen that consumers don’t fully understand how insurance coverage actually works until they get sick and try to claim insurance payments for the treatments or medical care they insured themselves. However, they are then surprised to learn that their policies does not pay as much, or at all, for care they thought would be covered.

To date, the Consumer Council of Fiji has received a total of 32 complaints in this area of medical insurance. Most of these complaints revolve around the issue that insurance companies use pre-existing medical conditions as a reason to decline insurance claims.

The emergence of ‘exclusionary products’ and ‘restricted products’ is of no help when the premiums keep increasing every year. In such cases, the insured is unable to realise the benefits of the premium payments made while having to pay for the medical costs from their own pockets in times of emergencies.

It has also been identified that the option to choose a medical facility where treatment can be done is restricted. Apart from restriction of choice, concerns also have come to light of the poor operative and post-operative care provided by the designated medical facilities. Such was the case in Aaron’s situation.

Aaron was facing problems with the bending of his right knee. As per his insurance policy, the insurer arranged for surgery at an approved hospital in India. Upon his arrival in India, Aaron was appalled with the state of his accommodation which was provided under his policy. The room hewas accommodated in had no windows and too small to move around with his luggage in the same room. With Aaron’s knee problem, he required ample space to make himself comfortable, however, this room which he had occupied for four days had barely any space to walk.

This situation, however, did not deter Aaron from proceeding with his scheduled surgery. Things worsened after surgery when he started facing more difficulties with the post-operative care. As highlighted by Aaron, he was not provided pain-killers on a timely basis and he was made to travel in a vehicle not suited for a patient with knee operation.

Upon returning to Fiji, Aaron continued to face great difficulty in walking despite the surgery. Ever since his return, he had been using a walking stick and the pain was still persistent.

It was not until another diagnosis by a medical consultant that it was discovered a corrective surgery was required on Aaron’s knee. The consultant suggested a medical facility in New Zealand for this corrective surgery. However, the insurer insisted that the surgery be done at the same hospital in India which had performed the initial surgery. This would simply mean that Aaron would have to go through the whole ordeal of poor accommodation and post-operative care again.Aaron was not willing to take a risk with his knee again. He had lost faith in that hospital and he was not willing to go through another ordeal with the same medical facility.

Aaron then lodged a complaint with the Consumer Council of Fiji and it was not until this intervention by the Council that the insurer agreed to pay for Aaron’s corrective surgery in New Zealand. After the surgery, Aaron was able to walk again without a walking stick and faced no problems in the bending of his right knee.

Currently, Fiji’s insurance industry is regulated by the Insurance Act (1998). The purpose is “to provide the regulation of the business of insurance, for the licensing and supervision of insurers and insurance intermediaries, and for related matters.”

There is clearly a need for the revision of this Act with the aim to strengthen consumer protection elements and to align the legislation with recent developments taking place globally. Such reforms will provide consumers with the confidence that the policies they purchase will provide them with real value.

We encourage consumers to visit the Council offices in Suva, Lautoka and Labasa or call the National Consumer Helpline toll free number 155 to seek advice and lodge a formal complaint.