November 14, 2017

How would you feel if despite undertaking a Health Insurance policy and paying all the required premiums, you are unable to claim it when the need arises? To make it worse, you do not have any options to take any action against the insurance provider.

One would feel simply frustrated to say the least. But not much can be done in cases where consumer does not exercise his/her responsibility.

The Council recently dealt with a case of such nature where the consumer despite taking up a Health Insurance policy was unable to claim it due to not following the requirements under his insurance cover.

Ramesh took up an annual health policy under the Outpatient Care from a prominent insurance provider in the Central Division in 2016. He paid $104.00 for the policy and a further $178.00 as the premium annually.

Under his insurance cover, Ramesh was asked to designate a private medical practitioner and a pharmacy which he would be visiting when required. Ramesh nominated a private medical practitioner and a pharmacy of his choice located in Nausori, which was convenient to him, as he was residing in that area.

In April, 2017, Ramesh fell sick and needed medical attention. However, instead of visiting his nominated medical practitioner, Ramesh ended up at another clinic contrary to the arrangements as per his policy. He was of the view that irrespective of which medical practitioner he is visiting, the health insurance policy will cover the costs incurred by him for medical practitioners’ consultations and treatments.

Alas, this was never the arrangement under his cover.

In May, 2017 when Ramesh filed his claim with the insurance company for the outpatient consultations and diagnostic services rendered to him, the claim was declined. Unsure of the basis of the rejection of insurance cover, Ramesh lodged his complaint with Council seeking justification on the matter.

The insurance company, in their response to the Council’s queries, clarified that Ramesh’s nominated and approved service provider was the medical practitioner in Nausori and not any

other medical practitioner. Further his medication claim could not be facilitated either as they were not purchased from the nominated and approved pharmacy in Nausori.

In addition, they clarified that the nominations of the service providers were done by the complainant and that their sales agent had explicitly explained the contents of the agreement to Ramesh.

The same information was relayed to Ramesh. Whilst he was not satisfied with the explanation, there was little that he could do as the agreement was signed by him.

A simple action contrary to the terms and conditions of the health insurance policy made Ramesh not eligible to make claims despite having paid for it.

It is worth noting that this is not the first time that the Council has come across cases pertaining to health insurance. The Council has on numerous occasions received grievances from consumers regarding:

• no pre-disclosures being given to consumers in regards to the actual coverage;
• delays in approving medical treatments;
• delays in payments;
• High out-of-pocket healthcare expenditure despite having an insurance cover;
• misleading claims about the nature of products provided by the insurance companies agents;
• pre- existing medical conditions;
• exclusionary clauses attached to the insurance policies;
• referral of insured consumers to public health facilities which consumers can access free of charge; and
• fine prints and technical jargons used in the policy that did not make sense.

The Council in its attempts to address the recurring health insurance related issues had earlier this year hosted a Health Insurance seminar in the presence of relevant stakeholders. The seminar gave the buyers of the health insurance policies an opportunity to speak out about issues pertaining to their policies. Alternatively, the regulators and insurance providers present during the discussions were able to take into account the complaints and feedbacks.

The Council anticipates that taking into account some of the grey areas surrounding the health insurance industry, possible changes are initiated soon for the benefit of consumers at large. The Council will continue lobbying for such changes.

In the meantime, consumers are encouraged to read and understand their policy terms and conditions properly before finalizing their covers.

Failure to read and understand one’s health insurance cover can cause unnecessary frustration to consumers when unable to utilize the paid funds. Not to mention incurring extra costs to meet the expenses which insurance covers do not cater for when they are bought with an understanding that it will take care of the same.